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I FINAL DRAFT Islamic Republic of Afghanistan Ministry of Public Health COMPREHENSIVE HEALTH CARE WASTE MANAGEMENT PLAN (HCWMP) FOR THE SYSTEM ENHANCEMENT FOR HEALTH ACTION IN TRANSITION (SEHAT) PROJECT October, 2014 E4073 V1 REV Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized

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Page 1: Islamic Republic of Afghanistan Ministry of Public Health€¦ · Ministry of Public Health COMPREHENSIVE HEALTH CARE WASTE MANAGEMENT PLAN (HCWMP) FOR THE SYSTEM ENHANCEMENT FOR

I

FINAL DRAFT

Islamic Republic of Afghanistan

Ministry of Public Health

COMPREHENSIVE HEALTH CARE WASTE MANAGEMENT PLAN (HCWMP)

FOR THE SYSTEM ENHANCEMENT FOR HEALTH ACTION IN TRANSITION (SEHAT)

PROJECT

October, 2014

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Page 2: Islamic Republic of Afghanistan Ministry of Public Health€¦ · Ministry of Public Health COMPREHENSIVE HEALTH CARE WASTE MANAGEMENT PLAN (HCWMP) FOR THE SYSTEM ENHANCEMENT FOR

II

Table of Contents

ABBREVIATIONS AND ACRONYMS V

EXECUTIVE SUMMARY 1

I. INTRODUCTION 21

BACKGROUND OF HCWM IN AFGHANISTAN: 21

II. POLICIES, LEGISLATION AND REGULATION 23

ENVIRONMENTAL PROTECTION ACT, 2007 23

MOPH STRATEGIC PLAN 23

INFECTION PREVENTION AND CONTROL POLICY, 2005. 24

WORLD BANK SAFEGUARD POLICIES 24

IAEA SAFETY STANDARDS SERIES OCCUPATIONAL RADIATION PROTECTION 25

HEALTH CARE WASTE 26

III. SITUATION ANALYSIS OF HCWM IN AFGHANISTAN 27

STRUCTURE OF THE HEALTH CARE SERVICES DELIVERY SYSTEM: 28

PRIORITY POLICIES: 28

DEVELOPMENT OF COMPREHENSIVE HCWM PLAN 29

CURRENT HEALTH CARE WASTE MANAGEMENT PRACTICES IN THE AFGHANISTAN HEALTH CARE CENTERS: 31

WASTE ESTIMATE 34

DISPOSAL SITE ANALYSIS 37

SCAVENGING & RECYCLING 37

TRAINING NEEDS ASSESSMENT 38

IV. HEALTH CARE WASTE MANAGEMENT PLAN 38

V. ORGANIZATIONAL ARRANGEMENTS FOR IMPLEMENTATION 55

A. NATIONAL LEVEL 55

B. PROVINCIAL LEVEL: 56

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III

VI. OPERATIONAL FRAMEWORK 64

AWARENESS AND TRAINING 72

VII. MONITORING 75

VIII. BUDGET 78

DISCLOSURE 0

LIST OF REFERENCES 0

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IV

List of Tables & Figures

Table 1: Current status of health care waste management practices. ......................................................... 5

Table 2: Gaps and Objectives for HCWM ...................................................................................................... 8

Table 3: Health Care Waste Categories and Descriptions .......................................................................... 26

Table 4: Health Effects and Potential Hazards from Clinical Wastes .......................................................... 27

Table 5: Existing Waste Management Practices in Afghanistan ................................................................. 32

Table 6: Illustration of Estimate of Healthcare Waste Generation in Afghanistan ................................... 35

Table 7: Quantity of HCW in Afghanistan .................................................................................................. 36

Table 8: Training Needs Assessment ...................................................................................................... 38

Table 9: HCWM Plan Activities of Major Components ............................................................................... 40

Table 10: Recommended Color Codes ........................................................................................................ 46

Table 11: Health Care Waste Management guidelines (HCWMP) Matrix for SEHAT ................................. 50

Table 12: Categories of health-care waste and their final disposal decision matrix .................................. 53

Table 13: Role of different stakeholders in health care waste management............................................. 59

Table 14: Additional regulatory guidelines ................................................................................................. 59

Table 15: Proposed implementation schedule for HCWM Plan ................................................................ 63

Table 16: General Waste Management Rules ............................................................................................ 68

Table 17: SHC, BHCs, and CHCs’ Wastes ..................................................................................................... 69

Table 18: Instruction for use of AD syringes ............................................................................................... 70

Table 19: Training of the Trainers (TOT) Program ...................................................................................... 73

Table 20: List of Indicator for monitoring of HCWM .................................................................................. 76

Table 21: Phase Manufacturing Program for the major Equipment & consumables ................................. 78

Table 22: Estimate of Financial Requirement for Training, Capacity Building and IEC (US Dollar) ............ 81

Table 23: Estimate of Financial Requirement for Technology Up-gradation and new Procurement (US

Dollar) .......................................................................................................................................................... 81

Figure 1: Sample Wheeled Vehicles (Source: WHO) ................................................................................... 49

Figure 2: International Infection Substance Symbol ................................................................................... 49

Figure 3 : Schematic Representation of Institutional Capacity building of various stakeholder for proper

implementation of HCWM plan .................................................................................................................. 58

Figure 4: Existing HCWM- M&E Framework .............................................................................................. 75

Figure 5: Year wise Investment Required ................................................................................................... 79

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List of Annexure

ANNEXURE II: MAJOR SCOPE OF WORK ....................................................................................................... 1

ANNEXURE III: COPY OF THE QUESTIONNAIRES USED................................................................................. 5

ANNEXURE IV: LIST OF CONTACTS ............................................................................................................ 115

ANNEXURE V: GUIDELINES FOR SETTING UP WASTE MANAGEMENT COMMITTEE................................ 120

ANNEXURE VI: GUIDELINES FOR CONSTRUCTION SHARP AND BURIAL PITS ............................................... 0

ANNEXURE VII: COMPARATIVE EVALUATION OF DIFFERENT TECHNOLOGY ................................................ 0

ANNEXURE VIII : GUIDELINES FOR SETTING UP OF CWTFs ........................................................................... 0

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VI

ABBREVIATIONS AND ACRONYMS

AD : Auto Disabled

AHNSS : Afghanistan Health and Nutrition Sector Strategy

ARTF : Afghanistan Reconstruction Trust Fund

BHC : Basic Health Centre

BPHS : Basic Package of Health Services

CBHC : Community Based Health Center

CBR : Capacity for Result

CDC : Center for Disease Control and Prevention

CHC : Comprehensive Health Centre

CWTF : Common Waste Treatment Facility

EC : Environmental Clearance

EMP : Environment Monitoring Plan

EMS : Environmental Management System

EPHS : Essential Package of Health Services

ESMF : Environmental & Social Management Framework

GDo PM : General Directorate of Preventive Medicine

GIZ : Deutsche GesellschaftfürInternationaleZusammenarbeit (GIZ)

GoA : Government of Afghanistan

HCS : Health Care Services

HCU : Health Care Unit

HCW : Health Care Waste

HCWM : Health Care Waste Management

HCWMP : Health Care Waste Management Plan

HFs : Healthcare Facilities

HMIS : Health Management Information System

HNS : Health and Nutrition Sector

HW : Health Worker

IMEP : Infection Management and Environment Management Plan

IP : Infection Prevention

M&E : Monitoring and Evaluation

MDGs : Millennium Development Goals

MOPH : Ministry of Public Health

MSW : Municipal Solid Waste

NEPA : National Environmental Protection Agency

NGO : Non-Governmental Organization

PPA : Performance-based Partnership Agreement

PPE : Personal Protective Equipment

PPD : Provincial Project Directorate

PPP : Public Private Partnership

RBP : Results Based Planning

SC : Sub-Centre

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VII

SEHAT : System Enhancement for Health action in Transition

SHARP : Strengthening of Health Activities for the Rural Poor

SHC : Sub health Center

SLF : Sanitary Landfilling

TPD : Tones per day

UNEP : United Nation Environment Program

USAID : United State Agency for International Development

WB : World Bank

WHO : World Health Organization

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EXECUTIVE SUMMARY

1. MAIN OBJECTIVE

The main objective of this document is to provide an environmentally sound, technically feasible,

economically viable and socially acceptable healthcare waste management Plan for Afghanistan with

cost implication and timeframe for implementation of the same.

2. DEFINITION OF HCWM: Health care waste management (HCWM) is a process to help ensure

proper hospital hygiene and safety of health care workers and communities. It includes planning and

procurement, construction, staff training and behavior, proper use of tools, machines and

pharmaceuticals, proper disposal methods inside and outside the hospital, and evaluation. Its many

dimensions require a broader focus than the traditional health specialist or engineering point of view.

3. ADVANTAGES OF GOOD HCWM

The need for proper HCWM has been gaining recognition slowly. It can help control nosocomial

diseases (hospital acquired infections), complementing the protective effect of proper hand washing;

reduce community exposure to multi-drug resistant bacteria; dramatically reduce HIV/AIDS, sepsis,

and Hepatitis transmission from dirty needles and other improperly cleaned/disposed medical items;

control zoonosis (diseases passed to humans through insects, birds, rats and other animals); cut

cycles of infection; easily and cost-effectively address health care worker safety issues, including

reducing risk of needle sticks; prevent illegal repackaging and resale of contaminated needles; avoid

negative long-term health effects; e.g., cancer, from the environmental release of toxic substances

such as dioxin, mercury and others.

HCW can be subdivided into various categories. Segregation of different waste categories is

critically important to enable proper disposal. Approximately 80% of all HCW can be disposed of

through regular municipal waste methods. The other 20% can create serious health threats to health

workers and communities if not disposed of properly. Disposal methods vary according to type of

waste, local environment, available technology, costs and financing, and social acceptance. Lance

Healthcare Waste (HCW): All waste produced in a health-care unit is defined as Health-Care

Waste but practically 75-90% of HCW is general waste which is non-infectious and similar in nature

to Municipal Solid Waste (MSW).

The remaining 10-25%of the HCW comprising of Infectious Waste (Sharp Waste, Contaminated

dressings, anatomical and body parts), Chemical or Pharmaceutical Waste and small amounts of

radioactive, cytotoxic or Mercury-based waste, represents an elevated risk as a source of potential

infection, injury or other health impact. A miniscule fraction (generally less than1%) may pose a

serious chemical, radiological or physical hazard.

Infectious waste, if not managed properly, can endanger the health of patients, health-care workers,

waste-pickers and the people at large and can lead to people dying or getting injured or sick. Sharps

Waste poses the highest risk among the entire range of Infectious HCW. The WHO estimates that the

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unsafe injection practices may cause 1.3 million people1 premature death a year. Improper

occupational practices and waste handling of infectious waste poses a high risk to health care

workers, environment-service staff, waste handlers and the general public.

Waste generated from specific programs/projects is also classified as a HCW. The improper usage of

insecticides, pesticides etc. such as rodenticides for control of rats and mice, antimicrobial pesticides,

bleach etc. can result in increased contamination of soil and water if precautionary measures are not

taken. The final step in rendering the HCW non-infectious is its treatment and disposal. Various

technologies are available as alternatives for treating different types of HCW including Chemical

Infection, Incineration, Autoclaving, Hydroclaving, Microwaving and the Deep Burial.

There is need to build up the local skills and the expertise for operating the various types of HCWM

equipment including the incinerators, autoclaves, microwaves, chemical disinfection, sharps

management, as well as the operation of the sanitary land filling facilities. The operational skills as

well as the construction technology for the Deep Burial Pits also need to be developed.

4. HEALTHCARE SERVICES DELIVERY SYSTEM IN THE COUNTRY

Healthcare Services is provided in the country through BPHS and EPHS packages.

a. Basic Package of Health Services (BPHS)

The purpose of developing the BPHS was to provide a standardized package of basic services

that would form the core service delivery package in all primary health care facilities. The

BPHS represented a roadmap that provided policymakers with a clear sense of direction and

emphasized essential primary health care as the basis of the health system. As a result, the

BPHS has been the catalyst behind the establishment of strong understandings between the

MoPH and its major partners; namely the BPHS implementing NGOs and the donors.

The standardized classifications of health facilities that provide the basic services now include

the following:

o Health Posts (HPs)

o Health Sub-centers (HSCs)

o Basic Health Centers (BHCs)

o Mobile Health Teams (MHTs)

o Comprehensive Health Centers (CHCs)

o District Hospitals (DHs)

The major healthcare services provided under the BPHS include Maternal and New born care,

Child Health and Immunization, Public Nutrition, Communicable Disease and Treatment and

Control, Mental Health and Disability and Physical Rehabilitation services and regular supply

of essential drugs.

1 Bulletin of the WHO,1999,77(10)

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Thus type of HCW which could be generated through the BPHS package would include

Anatomical Waste, Sharps, Infectious Waste including dressing etc. b. ESSENTIAL PACKAGE OF HOSPITAL SERVICES (EPHS)

The Essential Package of Hospital Services (EPHS) has three purposes: (1) to identify a

standardized package of hospital services at each level of hospital, (2) to provide a guide for the

MOPH, private sector, nongovernmental organizations (NGOs), and donors on how the hospital

sector should be staffed, equipped, and provided materials and drugs, and (3) to promote a

health referral system that integrates the BPHS with hospitals. The EPHS defines, for the first

time, all the necessary elements of services, staff, facilities, equipment, and drugs for each type

of hospital in Afghanistan.

These packages have direct relation with the healthcare waste generation, handling and management

of the same in the country. The improvement of healthcare services delivery system means increment

in number of people who would get more accessibility of healthcare services and treatments. This

would require consideration while formulating the healthcare waste management plan in the country.

5. DEVELOPMENT OF COMPREHENSIVE HEALTHCARE WASTE

MANAGEMENT PLAN

The MoPH developed a Preliminary HCWM Plan for the first 6 months of the SEHAT project in

2012. The major interventions that were recognized included development and adoption of

guidelines for effective healthcare waste management, creating awareness and training to the end

user/the waste producer/waste handler.

The preliminary HCWM plan was not purported to cover many issues in detail.

The MoPH recruited and international consultant to work on development of a comprehensive

healthcare waste management plan. The consultant along with the officials from the Environmental

Health Directorate, MoPH undertook field visits in Kabul, Ghazak, Parwan, Panjashir, and Balkh

Provinces having detailed interactions with various stakeholders such as the HCFs( National

Hospitals, Regional Hospitals, Provincial Hospitals, District Hospitals, CHCs, BHCs), International

Funding Agencies, Department of MoPH, NGOs, Landfill Sites, Municipalities, Regulatory bodies,

other relevant agencies etc. Structured Questionnaires were used for eliciting responses from the

HCFs in addition to interaction with the Staff there. For other respondents, unstructured and Semi-

structured Questionnaires were used to get their inputs, in conformity with the objectives of the

HCWMP.

The inputs from the desk research, and interaction with the stakeholders were useful in assessing the

regulatory framework and its compliance in practice, present status of HCWM at different types of

HCFs, quantities of HCW generated, current technology in use for treatment of HCW and its

disposal, Monitoring & Evaluating mechanism, Training Needs Assessment etc. The specific issues

such as segregation of HCW and color coding practices, type of equipment in use for collection &

transportation, use and disposal of Sharps, development of Landfill facilities for HCW disposal,

status of Infection Control etc. were addressed. The plans for management of HCW from rural areas

have been worked out separately based on the interaction with the various stakeholders

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These inputs were useful in developing recommendations for the HCWM Plan. A gap analysis was

also undertaken to compare the present status and the recommendations made. The Comprehensive

HCWMP duly incorporates the gap analysis as well as the capacity of the various stakeholders to

adopt and implement the proposed plan.

The plan contains major guidelines to be followed during the implementation stage , provision of

pilot projects for CWTFs, alternate technologies for the remote and rural areas, 3rd party monitoring

and evaluation framework, format & contents of training programs, procurement policy for major

treatment technologies and safety equipment, construction guidelines for sharp and burial pits etc.

apart from other aspects such as Segregation, Color Coding, Infection Management , Transportation,

Disposal, Sharps Waste Management etc.

6. REVIEW OF EXISTING POLICY FRAMEWORK

Existing Policy Framework which are relevant for Healthcare Waste Management include:

i) Constitution of the Islamic Republic of Afghanistan

ii) Environmental Law of the Islamic Republic of Afghanistan , 2007

iii) Environmental Impact Assessment Regulations, 2007 & 2008

iv) MoPH Strategic Plan, 2011

v) Infection Prevention Control Policy, 2005

vi) World Bank Safeguard Policies

vii) IAEA Safety Standards Series Occupational Radiation Protection

On assessment of existing policies, the finding is that there is a enough provisions to deal with the

healthcare wastes but the role and responsibility are not clear. It creates ambiguity about the

accountability at each level from regulatory authority to healthcare service facilitators. This makes it

imperative that the country should have a clear cut rules and regulation, guidelines and standards to

be maintained, establishment of linkages between different applicable acts and policies, designation

of body, a waste management committee, functions, clear guidelines on ‘reporting system and

provision of 3rd

Party Monitoring and Evaluation. Like other country, this rule can be christened as

‘Healthcare Waste Management & Handling Rule’.

7. ESTIMATE OF HEALTHCARE WASTE GENERATION IN AFGHANISTAN

The estimate of Healthcare Waste (HCW) and the Biomedical Waste in Afghanistan has been

worked out on the basis of prevailing norms of generation of Anatomical Waste, Sharps Waste and

other Infectious wastes as well as the general waste (please see Table 4. The total HCW generated in

Afghanistan is approx.150 tons per day of which about 27 tons per day is the Bio Medical waste and

the rest is the General Waste.

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There are around 1989 Health Care Unit situated in Afghanistan and gross total waste generated is

27.0 tones out of which 6.6tonnes are anatomical wastes, 14.8 are sharp wastes and 5.6tonnes are

other infectious wastes2.

The HCW generation in Afghanistan has been worked out on the basis of the number of different

types of HCUs and the HCW generated at each of these units from the OPD facilities as well as In

house Patients (see Table 4 & 5,

8. EXISTING WASTE MANAGEMENT PRACTICES IN AFGHANISTAN

The prevailing Healthcare Waste Management Practices in Afghanistan has been given below in

tabular form. It has been prepared based on discussions with various stakeholders

Table 1: Current status of health care waste management practices.

Operation Existing Practices/Status

Waste Generation i) Waste Generation not monitored primarily because of lack of

proper collection and segregation

Waste Collection i) Waste Collected from the OT, General Wards, OPD Lab etc, gets

mixed generally.

ii) Apart from the sharps & Placentas, most of the other waste is

collected

iii) Needle-cutters/Hub –Cutters not used generally

Waste Segregation i) General Waste, anatomical waste, & other Infectious wastes are

normally collected separately at the point of generation

ii) Sharps (used AD syringes) collected separately in yellow Boxes,

but end up getting mixed during transportation.

iii) Patients/Visitors in the wards sometimes dump the general waste in

the bins near the Nursing Stations

Color Coding i) Color-coding exists only as far as usage of yellow Boxes for used

AD syringes and Black bins for other wastes

ii) No Color-Coding for Bags & the trolleys in which wastes are

transported

iii) The color-coding for different types of HCW is not consistent

and used more as an exception than as a rule lack of Consistency

in color-coding often results in different types of HCW getting mixed

Waste Transportation i) Primary Waste Transportation3 in Bags Carried manually by

trolleys by the Hospital Sanitation Workers

ii) Secondary Transportation is non-existent as the disposal takes place

inside the HCU primarily.

Training i) Most of the Doctors, Nurses & Para-medical staff have been trained

in Infection Prevention as per the Country’s IP Policy

ii) The training schedule & re-training as per the IP Policy is not

followed.

2 Health Care Waste assessment report, produced by Pradeep Dadlani.

3 Primary Transportation is the transportation of the waste from the point of generation to the secondary storage area

within the healthcare facilities; Secondary Transportation is the process of moving wastes from the secondary storage

areas to the Treatment/Disposal Site.

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iii) Virtually no training is being done on HCWM

Waste Management

Committee

i) No Provision for a waste Management Committee at HCU level

ii) Focal Person for HCWM not appointed in most of the HCUs

Secondary Storage4

i) No proper provision for Secondary Storage of HCW.

ii) No timeframe earmarked for Secondary storage of HCW before its

disposal.

Treatment & Waste

Disposal

i) No clear cut policy on HCW treatment and disposal

ii) After basic segregation, all hazardous waste either burnt in

ovens/single chamber Incinerators or is buried inside the compound

iii) No disinfection equipment such as

Microwave/Autoclaves/Shredders installed except a few hospitals

Technology i) No Comparative evaluation of various technologies for HCW

treatment has been or is being done.

ii) A low level of technology is in use for HCWM e.g. Single

Chamber Incinerators ovens, Drums, Cemented Kilns etc.

Equipment i) The equipment for HCW waste collection, transportation,

treatment & disposal is of poor quality with no clear set of

guidelines

ii) Non-standardized equipment is being used mostly.

Personal Protective

Equipment PPE

i) The PPE such as gloves, goggles, mask boots etc. is used partially

in some of the hospitals.

ii) The guidelines provided in the IP Policy are also not followed in

general

iii) No mechanism to monitor the extend of usage of PPE

Monitoring & Evaluation i) No M&E mechanism for HCWM is in place at HCU level

ii) M&E for HCWM recently included the work Profile for the NGOs

under the SEHAT project in the fresh bidding process undertaken in

2013

Action Plan i) No road map for implementing HCWM Plan in Place at the Central,

Provincial or the HCU level

Finance i) No separate budget for financing mechanism for HCWM provided

ii) At the HCW level there is also no budget for HCWM provided, not

even for operational costs such as Fuel for the installed incinerator

Public Private Partnership

(PPP

i) PPP in the Health Sector of providing BPHS & EPHS through

NGOs has been a success story by & large

ii) However the same is not replicated in the HCWM Sector

Personal Hygiene &

Sanitation & Pollution

Abatement

i) No major focus on Personal Hygiene such as washing of hands PPE

etc.

ii) Water Quality at HCU level & Ambient Air Quality ( where

Incinerators used) is not monitored

Construction i) Construction Guidelines for Hospital buildings exist at MoPH, but

are outdated and not followed in practice

Integrated Holistic

Approach

i) Piecemeal approach to HCWM observed at the HCU level as well

as at the Provincial, Regional & National Levels

Capacity Building of

Env. Health Department,

MoPH& other

i) No Capacity Building exercise undertaken

4 ( Storage area earmarked within the premises of the healthcare facilities for storage of wastes from different

sources)

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stakeholders

9. DISPOSAL SITE ANALYSIS

Although Bio-Medical Waste accounts for a small fraction of HCW, if it gets mixed with large

volumes of non-infectious waste and MSW, the problem gets compounded in terms of the potential

adverse effects.

The ash from the incinerators must be disposed of in a Sanitary Landfill site. Discussions with the

Sanitation Department of Kabul Municipality revealed that a sanitary landfill (SLF) site is under

development for the MSW generated in the city. Similar SLF sites could be planned in the other

major regional centers such as Jalalabad, Herat, Ghazni, Mazar-I-Sharif cities.

The availability of the soil cover required for covering the landfilled waste on a daily basis is an

important factor in planning and designing of a SLF site. The other important criteria which need to

be considered for the Disposal/SLF Site include the soil characteristics at the site, ground and surface

water analysis, quantum of waste to be landfilled, provision for a recycling/processing facility,

availability of land, terrain and other local factors etc. All these factors need to be taken into account

while planning a Disposal/SLF.

A visit to the Gazak Landfill site revealed that presently the HCW mixed with the MSW is being

disposed of at the site. Aerobic composting of the organic fraction of the MSW is taking place. An

area of 4000 m2 has been earmarked at the Ghazak- II landfill site for disposal of HCW generated in

Kabul.

10. ASSOCIATED UTILITY SERVICES

The basic utility services such as Sanitation, Water Supply and Solid Waste Management are an

important factor in protecting patients and staff from potential risks. Inadequate and poor

management of these services could have adverse impacts, such as outbreaks of water-borne diseases

including Viral Hepatitis, Typhoid, Cholera, Diarrhea etc. Moreover, poor management of the non-

infectious general waste such as inadequate storage, poor collection and disposal could attract stray

animals waste-pickers thereby becoming grounds for vector-borne, water-based and fecal-oral

infections. The dumping of solid wastes around the HCU could cause blockage of access roads,

water and sewage drains, resulting in an unhygienic environment for protection of health services.

During the field study it has been found that hospitals located in urban areas are well connected with

Municipal Solid Waste System and collection and transportation of general wastes are being done on

an regular basis but incidence of mixing up of general wastes with healthcare wastes often takes

place. This often takes place because of a number of reasons such as negligence, lack of segregation

at source and absence of devoted system to handle healthcare waste at the facility, absence of

stringent regulatory norms & penalty system and monitoring and evaluation framework.

11. SCAVENGING & RECYCLING

During the field visits to the hospitals, no major scavenging or rag pickers operations were

observed. This is probably due to the fact that the recycling industry in Afghanistan is not

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very advanced. However, at the major landfill/dumping sites across the country e.g. Gazak

in Kabul, some scavenging & recycling activity does exist.

12. HEALTH CARE WASTE MANAGEMENT PLAN

The preliminary plan concentrated on improving the existing Health Care Waste Management in the

health sector of Afghanistan, focusing on organizational and implementation arrangements, training

and financial implications. The Government of Afghanistan and the MoPH were committed to

undertake a proper sectoral assessment of HCWM and develop a comprehensive HCWMP within the

first six months of SEHAT implementation, which after approval by the WB would replace the

preliminary HCWMP with this comprehensive Healthcare Waste Management Plan.

At the preliminary stage the objective of the plan was to establish the following basic intervention

for health care waste management:

Develop/adopt and disseminate guidelines for the proper management of medical waste to

relevant stakeholders ;

Develop/ adapt and implement a training package for health workers on proper healthcare waste

management;

Increase public awareness and promote community participation in municipal solid waste

management (e.g. reuse, reduce and recycle);

Increase the number of health facility with incinerator;

To monitor the performance and review the Waste Management Plan at least annually;

Based on the situation analysis of HCWM in Afghanistan, the existing practices & status of the

major operations have been detailed to identify the gaps. Based on the identified gaps for different

operations the objectives for the HCWM plan have been worked out and the corresponding plan

activities for the major components have been highlighted below:

Table 2: Gaps and Objectives for HCWM

S.

N

Operations Existing Practices/Status Gap Objectives Plan Activities

1. Waste

Generation Waste Generation not

monitored primarily

because of lack of

proper collection and

segregation

Lack of

monitoring

,weighing

& record

keeping of

HCW

generated at

the HCF

Waste generation

to be monitored

quantitatively as

well as

qualitatively.

Extensive

Reporting

System &

procedures to be

put in place.

Daily reporting

system

suggested for

waste

quantification

& monitoring.

Also monthly

& quarterly

reports.

2. Waste

Collection Waste Collected from

the OT, General Wards,

OPD Lab etc., gets

mixed generally.

Improper

Inadequate

collection of

different

Color-coded

Bins for different

stream of HCW

i.e. Anatomical

Different types

of HCW to be

collected in

color-coded

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Apart from the sharps &

Placentas, most of the

other waste is collected

Needle-cutters/Hub –

Cutters not used

generally

streams of

HCW

Waste, General

Waste & Sharps

to be provided.

Needle

Cutters/Hub

Cutters to be

used for

separating used

plastic syringes

from needles

sharps

bags & bins as

per the HCWM

Plan

3. Waste

Segregation General Waste,

anatomical waste, &

other Infectious wastes

are normally collected

separately at the point of

generation

Sharps (used AD

syringes) collected

separately in yellow

Boxes, but end up

getting mixed during

transportation.

Patients/Visitors in the

wards sometimes dump

the general waste in the

bins near the Nursing

Stations

Improper

Segregation

of the

Wastes and

mixing of

the

segregated

wastes

during

collection &

transportatio

n

Different types

of HCW to be

segregated at

source through a

clear-cut color

coding system.

Color –coded

Bins to be

provide at

appropriate

locations in the

HCU.

No access to the

patients/visitors

to the Bins

placed near the

Nursing Station

and OT for

collection of

Infectious waste,

Anatomical

Waste & Sharps.

Designated

Color coding

system for

bags, bins,

trolleys &

secondary

storage planned

4. Color

Coding Color-coding exists only

as far as usage of yellow

Boxes for used AD

syringes and Black bins

for other wastes

No Color-Coding for

Bags & the trolleys in

which wastes are

transported

The color-coding for

different types of

HCW is not consistent

and used more as an

exception than as a

rule

Lack of Consistency in

color-coding often results

in different types of HCW

getting mixed

Inconsistenc

y in the

color-coding

for different

types of

HCW

Elaborate but

implementable

Color-coding

mechanism

suggested for

different types of

HCW

Consisted &

Uniform Color-

Coding for

Waste

Collection,

Transportation,

Secondary

Storage etc.

planned.

Consistent color

–coding for

HCW collection,

segregation,

transportation to

secondary

storage &

- Do -

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secondary

storage faculties

to usher in

uniformity and

alienate the

hazards of

mixing of the

waste & thus

ensuring a better

HCWM.

5. Waste

Transportati

on

Primary Waste

Transportation5 in Bags

Carried manually by

trolleys by the Hospital

Sanitation Workers

Secondary

Transportation is non-

existent as the disposal

takes place inside the

HCU primarily.

Unsafe

Primary and

Secondary

Transportati

on

Primary

Transportation in

Bags & Trolleys

with the same

color-codes as

the waste

collection Bins

Secondary Waste

Transportation

in closed

vehicles carrying

HCW symbol

and duly

authorized by

NEPA/Environm

ental Health

Department

Uniform color

coded trolleys

for primary

transportation

of segregated

HCW and

Authorized

vehicles for

secondary

transportation

from Hospitals

to the

Treatment/Disp

osal site

6. Training Most of the Doctors,

Nurses & Para-medical

staff have been trained

in Infection Prevention

as per the Country’s IP

Policy

The training schedule &

re-training as per the IP

Policy is not followed.

Virtually no training

is being done on

HCWM

Re-training

as per the IP

policy is not

done. The

refresher

training is

not provided

as per the

schedule

proposed in

the IP

Policy.

The IP training

procedures &

schedules to be

followed strictly

in accordance

with the IP

policy.

Detailed

Training Plan for

HCWM worked

out covering

different

stakeholders

Training Manual

to be prepared on

HCWM.

Special

emphasis and a

detailed

training plan

based on TNA

provided in the

HCWMP

7. Waste

Managemen

t Committee

No Provision for a

waste Management

committee at HCU level

Focal Person for

HCWM not appointed in

most of the HCUs

No

Institutional

Mechanism

to monitor

& record the

HCWM at

the HCU

level

Detailed Action

Plan&

Guidelines for

forming waste

Management

Committees at

the HCU

recommended.

Plan to include

a responsible

broad based

WMC with a

clearly

designated

Focal Point at

the HCU Level

5 Primary Transportation is the transportation of the waste from the point of generation to the secondary storage area

within the healthcare facilities; Secondary Transportation is the process of moving wastes from the secondary storage

areas to the Treatment/Disposal Site.

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11

Designated Focal

Point for HCWM

at the HCU level

made essential.

for HCWM

8. Secondary

Storage No proper provision for

Secondary Storage of

HCW.

No timeframe

earmarked for

Secondary storage of

HCW before its

disposal.

Improper

Secondary

Storage and

the

maximum

time for

storage/freq

uency of

collection

not defined

The maximum

timeframe for

Secondary

Storage for

different types of

HCW specified.

Provision for a

proper

secondary

storage system

in the hospital

and maximum

time of 48

hours

earmarked for

transportation

to the

treatment/

disposal site.

9. Treatment

& Waste

Disposal

No clear cut policy on

HCW treatment and

disposal

HCW either burnt in

ovens/single chamber

Incinerators or is buried

inside the compound

No disinfection

equipment such as

Microwave/Autoclaves/

Shredders installed

except a few hospitals

Lack of

Policy for

HCWM

measures

and low

quality

equipment

used for

treating

HCW

Policy guidelines

&

Implementation

Plan for HCWM

including

treatment &

disposal

suggested.

Usage of

Double-chamber

Incinerator,

Autoclaves and

shredder with

guidelines for

disposal of

Incinerator ash

Policy

framework on

CWTF

recommended.

Plan to include

technology and

specifications

of HCW

treatment

equipment and

operational

framework for

CWTF

10. Technology No Comparative

evaluation of various

technologies for HCW

treatment has been or is

being done.

A low level of

technology is in use for

HCWM e.g. Single

Chamber Incinerators

ovens, Drums,

Cemented Kilns etc.

Low level of

technology

in use in the

current

HCWM

practices

Comparative

evaluation

undertaken for

alternate

technologies for

different types of

HCW &

appropriate

recommendation

s made

Plan for

technology

adaption in the

local context and

for remote areas

also suggested

Appropriate

technology

guidelines at

various levels

of HCUs

including those

for remote

areas included.

11. Equipment The equipment for

HCW waste collection,

transportation, treatment

& disposal is of poor

Lack of

standardizati

on and

quality

Plan for

procurement,

Commissioning,

Maintenance of

Standards for

HCW treatment

equipment and

the broad

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quality with no clear set

of guidelines

Non-standardized

equipment is being used

mostly.

specification

s for HCW

treatment

the right type of

equipment

provided.

Broad standards

for each type of

equipment to be

used in HCWM

set &

documented

procurement,

commissions &

maintenance

plan to be

provided.

12. PPE The PPE such as gloves,

goggles, mask boots etc

is used partially in some

of the hospitals.

The guidelines provided

in the IP Policy are also

not followed in general

No mechanism to

monitor the extend of

usage of PPE

Guidelines

for PPE not

fully

followed as

laid down in

the IP policy

Clear-cut

guidelines on

usage of PPE by

various

stakeholders in

HCWM i.e.

Doctors, Nurses,

Para-medical

Staff and

Sanitation

workers

recommended

Strict adherence

to the PPE

recommended in

the IP Policy

recommended

Guidelines &

Framework for

usage of PPE

provided.

Plan to

strengthen PPE

usage as per the

IP Policy as

well as the

regular

monitoring of

the same.

13. Monitoring

&

Evaluation

No M&E mechanism for

HCWM is in place at

HCU level

M&E for HCWM

recently included the

work Profile for the

NGOs under the SEHAT

project in the fresh

bidding process

undertaken in 2013.

Lack of

M&E

mechanism

for HCWM

at the HCU

level

A definite M&E

framework for

HCWM

recommended

M&E by

Independent 3rd

Party

recommended in

addition to the

existing

structures

M&E

framework to

be included in

the Plan with

provision for

3rd

Party

monitoring of

HCWM at

Provincial &

National level

14. Action Plan No road map for

implementing HCWM

Plan in Place at the

Central, Provincial or

the HCU level

Absence of

a road-map

for

implementin

g HCWMP

An Action Plan

suggested for

implementing

HCWM at

various levels

incorporating the

time schedule,

Training Plan

and the costs

Action Plan

with time

schedules,

training, IEC &

financial costs

to be suggested

15. Finance No separate budget for

financing mechanism for

HCWM provided

At the HCW level there

is also no budget for

HCWM provided, not

No a

separate

budget for

HCWM

provided at

the HCU

level.

Financing

Mechanism with

Capital

Expenditure

(Capex) and

Operational

Expenditure

Financial

estimated

Budgets for

both Capital

Expenditure &

Operational

Expenditure for

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even for operational

costs such as Fuel for

the installed incinerator

(Opex over a 5

year period

provided in the

HCWM Plan.

Investments and

Costs for

separate heads

such as

Procurement of

equipment,

Training, PPE,

Maintenance

detailed.

HCWM to be

provided in the

Plan.

16. PPP PPP in the Health Sector

of providing BPHS &

EPHS through NGOs

has been a success story

by & large

However the same is not

replicated in the HCWM

Sector

PPP in the

HCWM

Sector not

operational

The scope of the

NGOs role to be

enhanced in

training &

capacity building

for HCWM

3rd party M&E

for HCWM

proposed.

Special emphasis

on a new PPP

model for

CWTF, proposed

for HCWM.

PPP role in

HCWM to be

strengthened with a

new CWTF model.

17. Personal

Hygiene &

Sanitation

& Pollution

Abatement

No major focus on

Personal Hygiene such

as washing of hands

PPE etc.

Water Quality at

HCU level & Ambient

Air Quality ( where

Incinerators used) is not

monitored

MoPH

construction

Guidelines

for HCUs

not followed

1) Monitoring

of Water

Quality and

Ambient

Air

including

HVAC

recommend

as per

NEPA

guidelines.

Develop new

construction

guidelines as

well as Plan to

conform with

the same to be

included.

18. Constructio

n Construction

Guidelines for Hospital

buildings exist at MoPH,

but are outdated and not

followed in practice

Need to

implement

stringently

1) Need to

develop

and adhere

to a new set

of

construction

Guidelines

emphasized

Need to include

in M&E

framework

19. Integrated

Holistic

Approach

Piecemeal approach to

HCWM observed at the

HCU level as well as at

the Provincial, Regional

& National Levels

Holistic

Integrated

approach

not followed

for HCWM

1) An

Integrated

approach

with an

inclusion of

various

stakeholder

s in the

HCWM

recommend

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14

ed.

20. Capacity

Building of

Env. Health

Department,

MoPH&

other

stakeholders

No Capacity Building

exercise undertaken

Lack of

capacity

among the

various

stakeholders

for

implementin

g HCWMP

1) Specific

actions such

as Exposure

visit to

India.

Orientation

Program on

HCWM for

functional

heads of all

departments

of MoPH

and

extensive

capacity

Building

measures at

the

Provincial

level

recommend

ed

Training and

Capacity

Building,

Exposure/Orien

tation visits

planned under

HCWM Plan.

21. Waste

Water

Treatment

Waste effluent generated

from healthcare facilities

and join the drainage

without treatment

Absence

onsite waste

treatment

system in

HCFs

2) To treat the

wastewater

effluent

generated

from HCFs

before

releasing to

drainage

Provision to

have

wastewater

testing, onsite

treatment,

categorization

of wastewater

from Medical

wards,

Laboratories,

OT, General

Area, OPD etc.

and Healthcare

waste

management

guidelines and

policy

13. ORGANIZATIONAL STRUCTURE

National Level: The responsibility for ensuring the implementation of the HCWMP

lies with the MoPH, which is the implementing agency for the SEHAT. The overall

responsibilities will be with the Secretariat (MoPH). The specific responsibility will be

of the Environmental Health Department under the General Directorate of Preventive

Medicine (GDoPM) of the MoPH. It is important to note that Environmental Health

Department and its designated Focal Officer for HCWMP implementation will work in

consultation with the GCMU on the HCWM activities and act as focal points to ensure

effective, successful implementation of this HCWM plan.

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Provincial Level: At the provincial level, Provincial Health Directorate (PHD) and

Implementing NGOs will be responsible for the implementation of HCWMP. The

provincial public health director will assign monitoring Focal Point having proper ToR

and will receive needed training for effective implementation of the HCWMP. At the

health facilities, this responsibility will lie with the Head of Health Facility.

District Level: At the district level, the HCWMP implementation, monitoring and

evaluation would be done by the designated focal person for HCWM for that province.

Head of the health facility located at the district center will be responsible for

implementing the Healthcare Waste Management Plan (HCWMP).

The following flowchart depicts the proposed organizational structure for HCWM

system in Afghanistan at the Provincial and National level.

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Chart 1: Organization structure for HCWM

14. PROPOSED ACTION POINTS TO BE UNDERTAKEN AT VARIOUS LEVELS AS

PART OF THE HCWM PLAN

The below action points to be undertaken at various level have been compiled on the basis

of field visits undertaken at different types of healthcare facilities including BHCs, HSCs,

CHCs in Afghanistan, review of existing policies WHO Guidelines & standards and other

relevant documents.

A. Highlight of major action points to be undertaken as part of HCWM Plan by

MoPH/NEPA 1) Training Kit & Manual (Dari & English versions). A manual would be developed and be

made available to the end user i.e. healthcare facilities as a reference book for the

following:

Setting up of Waste management Committee,

Factors to be considered for the selection of technology

Deputy Minister for Health

Service Provision

General Directorate of

Preventive medicine

Environmental Health

Directorate

Radiation

Protection Wash Environmental

Hygiene Food Safety Admin Training

Health Care Waste

Management

(Staffed with 7 Technical

Officers

Regional HCWM Officer

Provincial HCWM Officer

HCWM Focal Point at each

Hospital

HCWM Focal Point at each

BPHS Health Faculties

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17

Color codes to be practiced

Layout specifications for construction of Deep Burial Pits

Safety guidelines to be followed

Manual for Symbols and Labels to be used, routes layout etc.

Sharps Management Plan

B. Highlight of major action points to be undertaken by HCFs

Highlighted key action points have been identified for implementing HCWM Plan at HCFs

including HSCs/BHCs/CHC level are summarized as follows:

1) Formation of Waste Management Committee (WMC)comprising of Heads of the

Hospital, Nursing Superintendent, Doctor/Nurse from Infection Control Committee,

Sanitary Supervisor, Store-in Charge and supervisor of Housekeeping Staff.

2) In-charge Waste Management Committee who also would be the focal point for HCWM

at that facility would be given the responsibility to operate and monitor the management

of the HCW on a daily basis;

3) Standard segregation procedures should be set-up in all Afghan HCFs by implementing a

three bins system that would follow clear cut color coding system , a labeling system as

well as waste minimizing procedures;

4) The development of specific treatment/disposal methods according to the type and the

location of the HCFs where the waste is generated. For example, For the smaller HCFs

and those located in the remote areas with no access with the connectivity, deep burial

pits for both disposal off sharps as well as anatomical wastes would be provided in

conformity with the standard designed as given in the HCWMP.

5) Proper collection points/stores are needed to avoid indiscriminate dumping of the

healthcare wastes in the hospital compound where it contaminates the air and the hospital

environment.

6) An exhaustive Feedback system would be implemented at HCUs on parameters such as

quantity & characterization of HCW, training needs, requirements of HCWM equipment

and materials, future trends etc. This feedback would be used to dovetail and improve the

existing plan further.

The schematic diagram of HCWM Plan to be adopted at HCFs including HSCs/BHCs/CHCs is

presented below.

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15. Operational Framework

Hospitals and health facility (HSCs/BHCs/CHCs): As per the revised BPHS Package,

2010/1389 the BHC is a facility offering primary outpatient care, immunizations and

Maternal and Newborn care. Services offered include antenatal, delivery, and postpartum

care; newborn Care, nonpermanent contraceptive methods; routine immunizations;

integrated management of childhood illnesses; treatment of malaria and tuberculosis,

including DOTS; and identification, referral, and follow-up care for mental health patients

and persons with disabilities including awareness-raising. The CHC covers a catchment area

of about 30,000–60,000 people and offers a wider range of services than does the BHC. In

addition to assisting normal deliveries, the CHC can handle certain complications, grave

cases of childhood illness, treatment of complicated cases of malaria, and outpatient care for

mental health patients.

Storage Facility: The shortage of storage areas results in the mixture of waste or creation of

overflow which allows animals and scavengers easy access to infectious waste. Another area

of concern is the storage of insecticide stocks for vector control activities at primary

healthcare facilities. This tends to be poor, with insecticides often being stored close to

pharmaceutical stocks or in village houses where spraying operations take place. The

responsibility to supervise the internal collection of wastes, their transportation, availability

of waste bags, protective clothing and collection carts and crews should be given to a

designated officer i.e. the person in-charge of healthcare waste management at the HCF.

Infection Control: It is very important to note and recognize that infection control is the

responsibility of all healthcare professionals – doctors, nurses, pharmacists and others.

Preventing nosocomial infections requires a hygienic and sanitized environment and

maintenance of good practices and use of protective gear. Routine cleaning of the health

facility is absolutely essential, as that will keep the environment free from dust and soil.

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Spill Control: Spillage usually requires clean up only of the contaminated area. For spillage

of infectious material, however, it is important to determine the type of infectious agent; in

some cases, evacuation of the area may be necessary. Procedures for dealing with spillage

should specify safe handling operation and appropriate protective clothing.

Treatment and Disposal of Health Care Wastes

All HCFs should treat and dispose the medical waste as given below:

All sharps in their puncture proof containers should be disposed in the sharps pit, which

is to be located within the premises of the HCF.

Infected organic waste, after disinfection, should be taken to the onsite deep burial pits

and covered with a layer of lime and soil.

Infected recyclables such as plastics and metals should be first disinfected using bleach

solution and / or autoclaved before sent for recycling.

If there is no organized collection of garbage / municipal solid waste, the general /

communal waste – non-infected - should be managed as follows:

o Organic waste such as kitchen waste and leaf fallings put in a compost pit, which

is to be located within the premises. Standard composting methods such as

mixing the waste with leaf fallings and soil should be done. Compost will be

available within a few days and this should be used for the garden. Care must be

taken to ensure that the organic waste is not infected by segregating the infectious

waste at source.

o Recyclable material such as packaging material and paper should be sold to

authorized recyclers or to link with Municipal Wastes. Care must be taken to

ensure that the recyclable waste is not infected and kept separated from infectious

wastes at all times.

Segregation of Waste and Onsite Storage: Segregation of waste at source is a single

most important step in bio-medical waste management. Once bio-medical waste mixes

with general waste, the waste management problem magnifies and becomes

unmanageable. It is critical that wastes be segregated at the point of generation itself.

Transportation of health care Waste: Medical Wastes have to be transported both within the health facility

and from the facility to the final disposal location. Properly designed carts, trolleys and other wheeled

containers will be used for the transportation of waste inside the facilities. Wheeled containers shall be so

designed that they have no sharp edges. Waste handlers must be provided with uniform, apron, boots, gloves,

and masks, and these should be worn when transporting the waste as described earlier.

Use and Disposal of Auto-Disabled (AD) Syringes

The MoPH recommends that Auto-Disabled (AD) syringes are to be used for

immunization instead of glass or disposable syringes. In parallel to introducing AD

syringes, MoPH has also developed and disseminated detailed user guidelines that

outline steps that should be followed when using an AD syringe and its disposal.

16. AWARENESS AND TRAINING

a) Awareness: Every province should plan and undertake general awareness raising activities

for Infection Monitoring and Environmental Plan (IMEP), which should include all levels of

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20

healthcare facilities. All IMEP related awareness activities should be fully integrated with

those being undertaken under the other national health programs. Professional bodies like

health promotion department of MoPH can be involved in enhancing understanding and

promoting good practices. At the health facilities, appropriately located display of IEC

materials is most effective in ensuring that workers follow segregation, treatment and

infection control practices.

b) Public Consultation: It is proposed to have extensive public consultations at various levels

with different stakeholders such as NGOs, Hospital Administrators, Municipalities, Doctors

and other medical staff, elected representatives, community, relevant government ministries

and departments in Afghanistan such as NGOs, Hospital Administrators, Municipalities,

Doctors and other medical staff , elected representatives, community, relevant government

ministries and departments before the proposed HCWM plan is taken up for

implementation. It is also suggested that since the “ownership” by the various stakeholders is

an important criteria for its success, the HCWM plan may be subjected to minor changes &

modifications based on the feedback received during the Public consultations while meeting

the overall Environmental compliance criteria and the World Bank Safeguards.

c) Training:

i. Capacity Building at Central and Provincial Levels: The reinforcement of the

institutional capacity will be done at national and provincial levels through specific

technical training to support the HCFs in implementation of new HCWM policy

ii. Health Workers: The level of awareness among the health workers of the risks of

HCW, Good Practices in HCWM, Correct Procedures etc. is quite low. The HCWM

Concept has not been adequately propagated among the Health workers in general

and their limited awareness is broadly restricted to the Training and procedures

covered in the IP protocol.

Even the prescribed training schedules as per the IP Policy are not followed and a majority of the Health

Workers have not been imparted the updated training on IP. Visits to some of the HCUs located in the

remote/rural areas revealed that the Doctors and the Nursing staff there have not undergone these trainings

for a long period.

The PPHD will be responsible for training of its staff in HCWM plan implementation. There are two

modules for training modules – (i) train-the-trainer and (ii) regular on-going training within the health

facilities. The implementing NGOs will undertake a needs identification to facilitate planning and allocation

of budget for this activity. It is envisaged that all health facilities under intervention areas of the SEHAT

project have officially recognized trained health personnel who will be responsible for health care waste

management. Existing awareness and training materials can be used to further develop the skills for the

sound management of health care wastes. These resources will be available at MoPH and NGOs.

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I. Introduction

Health care Waste Management consists of solids, liquids, sharps, and laboratory waste that are

potentially infectious or dangerous and are considered bio waste.

It must be properly managed to protect the general public, specifically healthcare and sanitation

workers who are regularly exposed to healthcare waste as an occupational hazard. In hospitals,

medical waste, otherwise known as clinical waste, normally refers to waste products that cannot

be considered general waste, produced from healthcare premises, such as hospitals, clinics,

doctor’s offices, veterinary hospitals and labs.

Health related activities produce a considerable amount of waste on daily basis as a result of

preventive and curative service delivery. The composition of waste produced is in the form of

sharps (needles, syringes), non- sharps, blood and other body fluids being infected and non-

infected, chemicals, pharmaceuticals and medical devises. Health workers, waste handlers, users

of health facilities and the community are all exposed to health-care related waste and ill health

as a result of poor management. A good health-care waste management plan could result in

healthier communities thereby reducing the cost of health-care, as well as creating opportunities

for recycling. A few important principles of sound management of healthcare related waste

include:

Definition of a policy framework;

Assignment of legal responsibility for safe management of waste disposal to the waste

producers;

Allocation of adequate financial resources and cost recovery mechanisms;

High level of awareness on proper waste disposal among all health workers in all cadres, as

well as on part of patients/families/communities, particularly in case of infectious diseases,

such as tuberculosis.

Background of HCWM in Afghanistan:

Since the establishment of a new administration in 2002, the Afghan Government has given the

utmost importance to addressing the high rate of maternal and child mortality, especially in rural

areas. The MoPH undertook a series of critical and strategic steps: it defined a Basic Package of

Health Services (BPHS) and later an Essential Package of Hospital Services (EPHS); it

established a system for contracting on a large scale with international and national non-

governmental organizations (NGOs) for delivery of these services. The Ministry of Public

Health (MoPH) also prioritized monitoring and evaluation of health sector performance.

Through the deployment of predominantly local consultants, the MoPH addressed the human

resource capacity constraints in terms of managing NGO contracts, tracking health sector

progress through rigorous impact level monitoring and performing its stewardship functions

effectively.

The proposed support under System Enhancement for Health Action in Transition (SEHAT)

project in the health sector will ensure provision of basic services in the project area and past

achievements are sustained over time. It will build upon the current support programs of IDA,

ARTF and EU and make these more responsive to the present and future needs of the sector by

focusing on the medium term system development needs of the sector in a sustainable fashion.

With World Bank experience in sector wide and programmatic support, IDA will facilitate and

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support systems development and realignment of development assistance to the sector and move

towards a sectoral approach so that financing for the sectoral priorities can be better guaranteed

through a well-coordinated effort by development partners.

The mission of the MoPH for health in Afghanistan states that improve the health and nutritional

status of the people in an equitable and sustainable manner through quality health services

provision, advocating for the development of healthy environments and living conditions; and

the promotion of healthy lifestyles.”

SEHAT is proposed as a five year program to be funded through IDA and ARTF. The proposed

project will include support for BPHS and EPHS services in provinces traditionally supported6

by the Bank as well as the 10 provinces currently financially supported by the EU. The project

has two components:

Component 1: sustaining and improving BPHS and EPHS services: the project will support the

implementation of the BPHS and EPHS through Performance- based Partnership Agreements

(PPAs), i.e. contracts between the MoPH and the implementing non- government organizations

(NGOs). It will also support the government’s efforts at delivering the BPHS through contracting

in management services in designated provinces, and implementation of urban BPHS in Kabul

city (the urban BPHS may be extended to other cities). It will include support to improve access

to and quality of BPHS/ EPHS services, and training of additional community midwives and

community nurses. In addition, financing will be made available for marginalized population

such as prisoners and nomads and HIV/AIDS prevention services for targeted population sub-

groups.

Component 2: Building the stewardship capacity of the MoPH and system: a) public hospital

reform and regulation of both public and private provider; b) building regulatory frameworks

and capacity to conduct quality assurance of pharmaceuticals; c) building capacity for effective

health promotion; d) development and testing of innovative financing models for the sector; e)

building/ strengthening human resources management system including appropriate use of

technical assistance, and expanding/ creating training capacity for community midwifery,

community nursing and hospital management; f) strengthening procurement and fiduciary

system, and g) strengthening monitoring and evaluation including surveillance, HMIS, surveys,

operation research, to improve evidence- based decision making. The project will also benefit

from CBR support to the health sector.

Component 3: Strengthening program management (estimated total cost of US$10

million): This component will support and finance cost associated with system

development and stewardship functions of the MOPH

Objective of HCWM Plan: The main objectives of the plan is to identify the most appropriate

management and disposal system for health-care waste management in Afghanistan- appropriate

being defined as environmentally sound, technically feasible, economically viable, and socially

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acceptable – and to prepare a policy framework and five –year action plan (including both physical

investments and training activities) to put in place and implement this system.

II. Policies, Legislation and Regulation

In Afghanistan, existing Policy Framework which are relevant for Healthcare Waste

Management include:

i) Constitution of the Islamic Republic of Afghanistan

ii) Environmental Law of the Islamic Republic of Afghanistan

iii) National Environment Impact Assessment Policy 2007- Islamic Republic of Afghanistan

iv) MoPH Strategic Plan, 2011

v) National Infection Prevention Control Policy, 2005

vi) World Bank Safeguard Policies

vii) IAEA Safety standards series occupational radiation protection

Environmental Protection Act, 2007

Constitution of the Islamic Republic of Afghanistan: As per the article 15 of the Constitution, the

state is obligated to adopt necessary measures to protect and improve forests as well as the living

Environment which is also relevant for Healthcare Waste management in Afghanistan. Next step

undertaken by the Islamic Republic of Afghanistan is enactment of Environment Protection Act,

2007 as well as establishment of National Environment Protection Agency. Environmental

Protection Act, 2007, Chapter 4 on integrated Pollution control is directly relevant for Health

Care Waste Management issues:

Art 27: Prohibition against discharges

Art 28 : Pollution control licenses

Art 29: Reporting and containing discharges

Art 30: General prohibition and duty of care in relation to waste management

Art 31: Waste Management Licenses

Art 32: Hazardous waste management licenses

National Environment Protection Agency (NEPA), Afghanistan came in existence in 2005 and

was embodied as policy making institutions and regulatory authority in Afghanistan. The

institution draws all power and authority from Environment Act of Islamic Republic of

Afghanistan which was promulgated in the year 2007.

MoPH Strategic Plan

MoPH Strategic Plan (2011-15) developed by the Ministry of Public Health (MoPH) has 8

strategic Directions which also emphasis upon the regulation and standardization of quality health

services, advocate and promote healthy environment.

This advocates for and promotes healthy environments adopting the following strategic

objectives:

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1. Strategic Objective 1: To strengthen the stewardship role of MoPH in relation to

Environmental Health by developing regulations and clarifying roles and responsibilities

under the Environmental Health program

2. Strategic Objective 2: To advocate for increased availability of safe drinking water in order

to reduce the burden of disease from contaminated water;

3. Strategic Objective 3: To increase food safety practices to prevent food borne illnesses in

food service and retail establishments;

4. Strategic Objective 4: To develop a systematic framework to lead a national process to

reduce air pollution and promote clean air (in collaboration with the Environmental

Protection Agency)

5. Strategic Objective 5: To create a national multispectral radiation protection forum to agree

on and advocate for safe levels of radiation in the country including increasing industry and

public awareness of this issue

6. Strategic Objective 6: To create a national multi-stakeholder mechanism for the

management of garbage and hazardous wastes (including solid waste and healthcare waste)

7. Strategic Objective 7: To improve hygiene and sanitation throughout the country among the

general public and health workers;

8. Strategic Objective 8: To build capacity and improve occupational health and safety among

all workplaces;

Infection Prevention and control Policy, 2005.

The MoPH's National Policy on Infection Prevention and Control for Hospitals and Health

Centers (2005) provide the broad principles of Infection Prevention and control (IPC) for all

Afghanistan healthcare facilities. The procedures manual provides the specific guidelines for

implementation of effective IPC program in the hospitals and health centers. The objectives of the

manual are twofold i.e.

i) To facilitate the implementation of effective implementation of the national IPC policy

ii) To provide the technical guidance necessary for the clinical managers of health facilities to

be able to implement an effective IPC program

The IPC Program covers the Nosocomial Infection Surveillance system, Environmental

Sampling, occupation Health Program and Safe Injection Practices. The IPC for housekeeping,

waste disposal and pest control also has been provided.

World Bank Safeguard Policies

The World Bank classifies the proposed projects into one of the four categories depending on the

type, location, sensitivity, and scale of the project and the nature & magnitude of its potential

environmental impacts. Health Sector Projects are typically classified as Category B (issues are

relatively straightforward & mitigation measures are well-defined & implementable).

In category B, the borrower consults projects affected groups and local NGOs about the projects

environmental aspects and takes their views into account. Some of the desirable features of a

good safeguards management are the following:

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1) Anticipate Safeguards Consideration early in the project preparation process

2) Design Projects and Project Schedules to avoid downstream problems & delays

3) Assist Borrowers in complying with Safeguards work requirements

Vector Management in Public Health Projects is governed by The World Bank Operational Policy

4.09. The OP and BP apply to all projects involving Vector management, whether or not, the

project finances pesticide under the Pest management policy, the World Bank supports a strategy

that promotes the use of biological or environmental control methods and reduces reliance on

synthetic chemical pesticides used must:

i) have negligible adverse human health effects

ii) be effective against the target species

iii) Have minimal effect on non-target species and the natural environment

iv) Take into account the need to prevent the development of resistance

IAEA Safety Standards Series Occupational Radiation Protection

IAEA Safety Standards Series Occupational Radiation Protection in the Mining & Processing of

Raw materials (Safety Guide No. Rs –G-1.6)

Training in Basic health and Safety in relation to radiation may include the following:

i. The principles of radiation protection (limits and optimization)

ii. Basic quantities and units in radiation protection

iii. The properties of and hazards associated with radioactive materials

iv. The purpose & methods of estimating workers’ radiation does including the use of

individual monitoring & measurements

v. The proper practices to eliminate, limit or control radiation does to workers including

personal hygiene & basic techniques of dose reduction such as shielding, distance & time.

vi. The persons to be contacted on matters of radiation health & safety

vii. The obligations of workers under the regulations issued by the regulatory body

viii. The health effects of radiation exposure

ix. The meaning of warning signs

On assessment of existing policies, enough provisions to deal with the healthcare wastes exist but

the role and responsibility are not clear. It creates ambiguity about the accountability at each level

from regulatory authority to healthcare services facilitators. This makes it imperative that the

country should have a clear cut rules and regulation, guidelines and standards to be maintained,

establishment of linkages between different applicable acts and policies, designation of body, a

waste management committee, functions, clear guidelines on reporting systems and provision of

3rd

Party Monitoring and evaluation. Like other countries, this rule can be christened as

‘Healthcare Waste Management & Handling Rules, Islamic Republic of Afghanistan.

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Health Care Waste

The World Health Organization (WHO) defines health care waste as total waste generated by

hospitals, health care establishments, and research facilities in the diagnosis, treatment, or

immunization of human beings or animals, and other associated research and services. Hazardous

health care wastes can be categorized into different groups as presented in Table 3.

Hazardous clinical wastes pose risks to individuals exposed to them (both within and outside

establishments), to workers in waste disposal facilities, and scavengers. Potential hazards

associated with these wastes, especially their effects on human health are paramount (Table 4). It

is, therefore, necessary to examine such hazardous wastes from broader perspectives—that is,

from generation to collection, storage, and disposal.

Table 3: Health Care Waste Categories and Descriptions

Waste category Description and examples

Infectious Waste Waste suspected of containing pathogens (e.g., laboratory cultures, waste

from isolation wards, tissues, materials or equipment having been in contact

with infected patients, and excreta)

Pathological Waste Human tissue or fluids (e.g., body parts, blood and other body fluids, and

human fetuses)

Sharps Sharp waste (e.g., needles, infusion sets, scalpels, knives, blades, broken

glasses, etc.)

Pharmaceutical

Waste

Waste containing pharmaceuticals (e.g., expired pharmaceuticals or no

longer needed, contaminated items or containing pharmaceuticals [bottles,

boxes])

Genotoxic Waste Waste containing substances with genotoxic properties (e.g., waste

containing cytotoxic drugs [often used in cancer therapy], genotoxic

chemicals)

Chemical Waste Waste containing discarded chemical substances (e.g., laboratory reagents,

film developer, disinfectants which are expired or no longer needed,

solvents)

Wastes with high

content of heavy

metals

E.g., batteries, broken thermometers, and blood pressure gauges

Pressurized

containers

E.g., gas cylinders, cartridges, and aerosol cans

Radioactive waste Waste containing radioactive substances (e.g., unused liquids from

radiotherapy or laboratory research, contaminated glassware, packages or

absorbent paper, urine and excreta from patients treated or tested with

unsealed radionuclides)

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Table 4: Health Effects and Potential Hazards from Clinical Wastes

Potential hazards Health effects

Infectious agents Respiratory infections, genital infections, skin infections, Meningitis, AIDS,

Viral Hepatitis A, B, and C

Radioactive Carcinogenic and mutagenic, skin or eye irritation, nausea, headache, or

dermatitis ,Cancer, burn and skin irritation, headache, dizziness, and

vomiting

Sharps Double risk: injury and potential transmission routes for HIV, and Hepatitis

B and C from

contaminated sharp

Pressurized

containers

E.g., gas cylinders, cartridges, and aerosol cans , Injury from explosion

Hazardous

chemicals

Intoxication, burns and skin irritation, pollution of groundwater, surface

water and the air,

possibility of fire, poisoning

Pharmaceuticals Ineffective medical care from the consumption of expired pharmaceuticals,

pollution of

groundwater, surface water, and air

Genotoxic waste E.g., batteries, broken thermometers, and blood pressure gauges

III. Situation analysis of HCWM in Afghanistan and Development of Comprehensive HCWMP

To analyze the present situation of HCW management system in Afghanistan, the following approach &

methodology has been adopted.

i) Desk Research: After undertaking of ToR and preliminary meeting with the concerned

stakeholders, an exhaustive desk research and internet scanning were undertaken to analyze

the present status of the Health Care Waste Management (HCWM) in Afghanistan. The

regulatory provisions and the role of different key stakeholders were also analyzed during

the desk research. Information on the current magnitude of the problems and trends in

HCWM in Afghanistan including generation rates, composition, collection, handling and

disposal techniques etc. were also collected through published materials. The existing Draft

HCWMP was also analyzed during the desk research.

ii) Interaction with Stakeholders: The desk research was followed by one-to one

interaction with the key stakeholders. A sample of Basic Health Centers (BHC) and

Comprehensive Health Centers (CHCs) as well as the regional, provincial and national

level hospitals in Afghanistan were contacted through field survey to assess the Health

care waste generation, current disposal practices, composition of waste ,capacity of the

staff at various levels, Training needs etc.

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iii) Final HCWM Plan: The said plan will be finalized on receiving a consolidate

comments from the concerned stakeholders such as MoPH, Islamic Republic of

Afghanistan; the World Bank, Afghanistan, WHO, Afghanistan and other (NGOs etc)

Structure of the health care services delivery system:

The structure of the HCS system in Afghanistan is traditional. At the most peripheral level, community

health workers (CHWs) who are non-health professionals with limited but highly targeted training are the

initial point of contact for individuals seeking Health Care Services (HCS). The Basic Health Center (BHC),

a formal structure maintained by the MoPH, is staffed by health professionals and provides, at a minimum,

all of the services that comprise the BPHS. Comprehensive Health Centers (CHCs), the next level of the

system, provides the BPHS and additional services including minor and essential surgery. The District and

Provincial Hospitals offer a broader array of more sophisticated medical care and, at the pinnacle of the HCS

pyramid, tertiary hospitals in the major urban areas provide the most sophisticated care available in

Afghanistan’s public Health and Nutrition Sector. There is a large private and traditional HCS sector in

Afghanistan as well, about which relatively little is known. The MoPH is in the process of developing

regulation and process to fulfill its stewardship role on this aspect of the National HCS as well.

Priority policies:

In line with the Afghanistan Compact of July 2006, the overarching strategic objective of the MoPH is to

obtain nearly universal coverage of a standard BPHS through the Contracting Out initiative and the In 2003

(1382), the MoPH adopted the strategy of contracting out the delivery of the BPHS to non-state providers in

order to be able to concentrate fully on its role as steward of the Health and Nutrition Sector (HNS). The

BPHS is currently being delivered on a contractual basis with NGOs in 31 of the 34 provinces in

Afghanistan. In the remaining three provinces, the MoPH is following a Strategic Management approach by

which it is, essentially, contracting with its own staff, on the same terms as it contracts with NGOs. To

further strengthen and improve the health system in the country, the Essential Package of Hospital Services

(EPHS) was endorsed by the MoPH in July 2005. Now the BPHS and EPHS together represent the basic and

essential elements of the health system in Afghanistan.

Currently there are 2,221 Health facilities nationwide. These can be subdivided into the following categories

or groups:

a. National hospitals=26

b. Regional hospital= 6

c. Provincial hospital= 28

d. District hospital= 75

e. Comprehensive health center=392

f. Basic health center =822

g. Mobile Health Team 103

h. Sub health center = 526

i. Other = 233

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Because of implementation of the BPHS and the EPHS through the above listed health facilities, a significant

increase in the proportion of the population with access to basic health services has been recorded in the

country. The success of the BPHS is also demonstrated in the significant improvement in key Afghan health

indicators compared with 2003. Some of the achievements of these policies are:

i. By 2009, 75% of the population was covered since the BPHS launched in the year 2003 as

cited by the Health and Nutrition Sector Strategy (HNSS) 2007/08–2012/13.

ii. use of a modern birth spacing/family planning method among married woman increased

from 10% to 20%,

iii. receipt of antenatal care by pregnant woman increased by 60%

This shows that the health indicators have considerably improved. However, the healthcare waste

management system in the BPHS is inadequate in terms of collection, segregation, transportation and

disposal of healthcare waste as well as a lack of institutional mechanism for monitoring and evaluation of the

same. The major reason for this gap has been due to non-availability of funds, lack of awareness and training

at the HCU level.

Development of Comprehensive HCWM Plan

The MoPH developed a Preliminary HCWM Plan for the first 6 months of the SEHAT project in 2012. The

major interventions that were recognized included development and adoption of guidelines for effective

healthcare waste management, creating awareness and training to the end-user/the waste producer/waste

handler.

The preliminary HCWM plan was not purported to cover the following issues in detail:

a. Field study and interactions with the stakeholders

b. Detailed technology evaluation and assessment

c. Technical guidelines & standards to be maintained implementing the plan at the national

and provincial levels

d. Additional policy measures needs to be taken to strengthen the monitoring and evaluation

system,

e. Clear cut reporting system

f. Role & and responsibility for the management of the Healthcare Facilities (HCFs) and

provision of setting up Waste Management Committee (WMC) for effective HCW

management.

g. Level of awareness available among the most vulnerable due to direct contact with the

healthcare waste and associates infection risks such as patients, visitors, nurses, waste

collectors, doctors and management of the healthcare facilities.

h. A comprehensive implementation level healthcare waste management plan

The comprehensive HCWMP document has tried to address the aforesaid issues.

The preliminary HCWM plan was used as the starting point for developing a comprehensive HCWM

Plan by the consultant.

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The MoPH recruited and international consultant to work on development of a comprehensive healthcare

waste management plan. The Consultant along with the officials from the Environmental Health

Directorate, MoPH undertook field visits in Kabul, Ghazak, Parwan, Panjashir, Balkh etc. and had

detailed Interactions with various stakeholders such as the HCFs( National Hospitals, Regional

Hospitals, Provincial Hospitals, District Hospitals, CHCs, BHCs), International Funding Agencies,

Department of MoPH, NGOs, Landfill Sites, Municipalities, Regulatory bodies, other relevant agencies

etc. Structured Questionnaires were used for eliciting responses from the HCFs in addition to interaction

with the Staff there. For other respondents, unstructured and Semi-structured Questionnaires were used

to get their inputs, in conformity with the objectives of the HCWMP. A copy of the Questionnaire used

for HCFs is provided at Annexure III and the list of contacts undertaken by the consultant during the

course of preparation of the HCWMP is detailed at Annexure IV.

Various Reference documents and articles were perused by the consultant prior to embarking on the field

visits and also during the course of the HCWMP preparation. A partial list of these

publications/documents is provided under the title ‘List of References’.

The inputs from the desk research, and interaction with the stakeholders were useful in assessing the

regulatory framework and its compliance in practice, present status of HCWM at different types of

HCFs, quantities of HCW generated, current technology in use for treatment of HCW and its disposal,

Monitoring & Evaluating mechanism, Training Needs Assessment etc. The specific issues such as

segregation of HCW and color coding practices, type of equipment in use for collection & transportation,

use and disposal of Sharps, development of Landfill facilities for HCW disposal, status of Infection

Control etc. were addressed. The plans for management of HCW from rural areas have been worked out

separately based on the interaction with the various stakeholders. The major lessons learnt during the

interactions with the stakeholders have been highlighted in Table 7 (under the title ‘Existing Waste

Management Practices in Afghanistan’).

These inputs were useful in developing recommendations for the HCWM Plan. A gap analysis was also

undertaken to compare the present status and the recommendations made. The Comprehensive HCWMP

duly incorporates the gap analysis as well as the capacity of the various stakeholders to adopt and

implement the proposed plan.

The plan contains major guidelines to be followed during the implementation stage , provision of pilot

projects for CWTFs, alternate technologies for the remote and rural areas, 3rd

party monitoring and

evaluation framework, format & contents of training programs, procurement policy for major treatment

technologies and safety equipment, construction guidelines for sharp and burial pits etc. apart from other

aspects such as Segregation, Color Coding, Infection Management , Transportation, Disposal, Sharps

Waste Management etc.

Some of the major additional coverage in this Draft Comprehensive Healthcare Waste Management Plan

as compared to the Preliminary HCWM P is as follows:

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i) Exhaustive field survey in various provinces covering the National Hospitals, Provincial

Hospitals, Regional Hospitals, District Hospitals, CHCs and BHCs levels.

ii) Identifying the Role of various stakeholders for effective implementation of HCWM

Plan.

iii) An overview of the present Infection Prevention and Control Policy, its present status,

implementation issues and its integration into the suggested HCWMP.

iv) The present status of HCWM being practiced in the various HCFs across the country with

regard to HCW collection, transportation, Secondary Storage, Treatment & Disposal

during the implementation of the SEHAT project.

v) The inclusion of HCWM in the agreements/MoUs signed with the NGOs/Implementing

Agencies for effective delivery of health services under the SEHAT projects was also

studied.

vi) Coverage on the new concepts which emerged during the discussions with the

stakeholders e.g. Common Waste Treatment Facility (CWTF ) to have more centralized

facilities for treatment & disposal of Healthcare waste rather than at the individual HCF

level, wherever implementable.

vii) Identifying the roles, objectives & implementation aspects of Waste Management

Committee (WMC) at the HCF level.

viii) A broad Training Need Assessment (TNA) and formulation of training program along

with its cost structure and schedule.

ix) Site Analysis for Centralised Treatment & Disposal of Healthcare Waste management in

the big towns e.g. Kabul.

x) Implementation Schedule for the Healthcare Waste Management Plan along with its

rollout.

xi) Quantification of different types of Healthcare waste at the national level.

xii) Details on Monitoring & Evaluation mechanism to ensure effective implementation of the

healthcare waste management plan

xiii) Alternate models for the Healthcare facilities in the Urban areas and the remotely located

and rural HCFs where accessibility is low.

xiv) Design aspects for the Deep burial pits and the Sharp Pits.

xv) Consistent Color Coding system for collection of various types of HCW and during the

transportation and secondary storages stage as well.

This comprehensive Healthcare Waste Management Plan takes into the account the present status, the

regulatory framework, compliance issues as well as the capacity assessment at the various levels for

implementation of the said plan.

Current Health Care Waste Management Practices in the Afghanistan Health Care Centers:

The generation of MSW in Kabul has gone up exponentially from 300 TPD to 4500 TPD in last 20 years

with the unprecedented rise in the population. Field visits indicate that most of the health facilities are in

relatively good state and appear to be properly maintained by government. Water and sanitation at the health

facilities are poor. Pipe borne water supply facilities (Saripul, Samangan and Balkh) are either only

sparingly functional or do not exist. In the provinces, some wells dry up during the dry season or the water is

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polluted. Some of the well heads are polluted or wells poorly constructed. Toilet facilities are also either in a

poor state or not functional.

The Incinerators provided at health facilities are made up of local materials (bricks) and have broken down

and need rehabilitation. In a large number of instances traditional ovens rather than incinerators are used for

disposal of wastes. Some new incinerators may have to be constructed urgently too. However, the major

obstacle for improving the HCWM in the country is the lack of proper system from generation to

segregation, collection, transportation, decontamination and disposal in the right and standard manner. There

is no proper color coded bins identified for the collection of the HCWs, no proper collection or temporary

storage rooms and the HCWs are dumped in the open area in the hospitals compounds in many cases even in

the country capital Kabul. However, with the exception of proper disposal of the most hazardous categories

of waste (needles and syringes), there has been steady progress in Afghanistan on an effective, hygienic and

systematic approach to HCWM since the SHARP Project launched. It helped to identify the risk associated

with HCW and need to prepare HCWM Plan for the entire country.

The result of survey7 recently presented also provides information on the precautions and safety measures

interventions related to proper disposal of sharps and use of sterilizers, disinfectants at primary health

facilities as follows:

1. 83.9 % of HFs are using safety boxes or closed containers for disposal of used sharps,

2. Syringes are being disposed without being recapped at the 66.5% of HFs,

3. 37.2% of HFs indicated posted procedures for decontamination procedure steps,

4. Availability of basin with water source and soap disclosed in the 56.7% of HFs

5. Evidence that disinfectants are being used observed at the 66.1 % of HFs,

6. Evidence that the incinerator is being used regularly scored 67.5%,

7. Disposable syringes are being used for all injections, noticed in the 99.7 % of HFs,

8. Evidence for regular use of the sterilizer, found in 70.4% of HFs.

EXISTING WASTE MANAGEMENT PRACTICES

Based on personal interaction with the head of Health facilities, staff, onsite observation, existing waste

management practices in Afghanistan is provided at Table 3.

Table 5: Existing Waste Management Practices in Afghanistan

Operation Existing Practices/Status

Waste Generation Waste Generation not monitored primarily because of lack of

proper collection and segregation

Waste Collection Waste Collected from the OT, General Wards, OPD Lab etc, gets

mixed generally.

Apart from the sharps & Placentas, most of the other waste is

7 –National Health Services Performance Assessment 2011/2012– JHU/IIHMR

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collected

Needle-cutters/Hub –Cutters not used generally

Waste Segregation General Waste, anatomical waste, & other Infectious wastes are

normally collected separately at the point of generation

Sharps (used AD syringes) collected separately in yellow Boxes,

but end up getting mixed during transportation.

Patients/Visitors in the wards sometimes dump the general waste

in the bins near the Nursing Stations

Color Coding Color-coding exists only as far as usage of yellow Boxes for used

AD syringes and Black bins for other wastes

No Color-Coding for Bags & the trolleys in which wastes are

transported

The color-coding for different types of HCW is not consistent

and used more as an exception than as a rule

Lack of Consistency in color-coding often results in different types of

HCW getting mixed

Waste Transportation Primary Waste Transportation8 in Bags Carried manually by

trolleys by the Hospital Sanitation Workers

Secondary Transportation is non-existent as the disposal takes

place inside the HCU primarily.

Training Most of the Doctors, Nurses & Para-medical staff have been

trained in Infection Prevention as per the Country’s IP Policy

The training schedule & re-training as per the IP Policy is not

followed.

Virtually no training is being done on HCWM

Waste Management

Committee No Provision for a waste Management committee at HCU level

Focal Person for HCWM not appointed in most of the HCUs

Secondary Storage9

No proper provision for Secondary Storage of HCW.

No timeframe earmarked for Secondary storage of HCW before its

disposal.

Treatment & Waste

Disposal No clear cut policy on HCW treatment and disposal

HCW either burnt in ovens/single chamber Incinerators or is

buried inside the compound

No disinfection equipment such as

Microwave/Autoclaves/Shredders installed excepta few hospitals

Technology No Comparative evaluation of various technologies for HCW

treatment has been or is being done.

A low level of technology is in use for HCWM e.g. Single

Chamber Incinerators ovens, Drums, Cemented Kilns etc.

Equipment The equipment for HCW waste collection, transportation,

treatment & disposal is of poor quality with no clear set of

guidelines

8 Primary Transportation is the transportation of the waste from the point of generation to the secondary storage area

within the healthcare facilities; Secondary Transportation is the process of moving wastes from the secondary storage

areas to the Treatment/Disposal Site. 9 Storage area earmarked within the premises of the healthcare facilities for storage of wastes from different

sources.

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173.5, 26%

356, 54%

132, 20%

AnatomicalWaste

Waste sharps

Other

Non-standardized equipment is being used mostly.

Personal Protective

Equipment PPE The PPE such as gloves, goggles, mask boots etc is used partially

in some of the hospitals.

The guidelines provided in the IP Policy are also not followed in

general

No mechanism to monitor the extend of usage of PPE

Monitoring & Evaluation NoM&E mechanism for HCWM is in place at HCU level

M&E for HCWM recently included the work Profile for the NGOs

under the SEHAT project in the fresh bidding process undertaken

in 2013.

Action Plan No road map for implementing HCWM Plan in Place at the Central,

Provincial or the HCU level

Finance No separate budget for financing mechanism for HCWM provided

At the HCW level there is also no budget for HCWM provided, not

even for operational costs such as Fuel for the installed incinerator

Public Private Partnership

(PPP PPP in the Health Sector of providing BPHS & EPHS through

NGOs has been a success story by & large

However the same is not replicated in the HCWM Sector

Personal Hygiene &

Sanitation & Pollution

Abatement

No major focus on Personal Hygiene such as washing of hands

PPE etc.

Water Quality at HCU level & Ambient Air Quality ( where

Incinerators used) is not monitored

Construction Construction Guidelines for Hospital buildings exist at MoPH, but

are outdated and not followed in practice

Integrated Holistic

Approach Piecemeal approach to HCWM observed at the HCU level as well

as at the Provincial, Regional & National Levels

Capacity Building of

Env. Health Department,

MoPH& other

stakeholders

No Capacity Building exercise undertaken

Waste Estimate

There are currently 2,221 health facilities comprising of National Hospitals, Regional Hospitals, Provincial

Hospitals, District Hospital, Comprehensive Health Centre,

Basic Health Centre, Sub Health centre and other. The

break-up of these along with wastes generation have been

provided at Table 6.

The estimate of Healthcare waste and the Biomedical Waste

in Afghanistan has been worked out on the basis of

prevailing norms of generation of Anatomical Waste, Sharps

Waste and other Infectious wastes as well as the general

waste. The total HCW generated in Afghanistan is app.150

TPD of which about 27 TPD is the Bio Medical waste and

the rest is the General Waste.

Estimated Waste Composition in Afghanistan

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Table 6: Illustration of Estimate of Healthcare Waste Generation in Afghanistan

S.N

Type of HCU

App. Nos of

Units in

Afghanistan

Types of HCW Total Annual

Waste of

different

Types (Kg)

Gross total

Waste

Generated

(Tones)

Anatomic

al Waste

Per unit

(kg)

Waste

Sharps

Per

unit

(Kg)

Other

Infectious

Waste incl.

Dressings

Per unit

(kg)

1 National HCU 24 80 160 60 300 7.2

2

Regional

Hospital 6 57 120 42 219 1.3

3

Provincial

Hospital 28 19 40 14 73 2.0

4 District Hospital 69 7 15 7 29 2.0

5

Comprehensive

Health Centre 379 2 5 2 9 3.4

6

Basic Health

Centre 812 1 4 1 6 4.9

7 SHC 472 1 2 1 4 1.9

8 Others 199 6.5 10 5 21.5 4.3

Total 1989

27.0

The HCW generation in Afghanistan has been worked out on the basis of the number of different types of

HCUs and the HCW generated at each of these units from the OPD facilities as well as In house Patients

(please refer Table 7)

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Table 7: Quantity of HCW in Afghanistan

S.N Type of HCU

Types of Bio-Medical Waste

Anatomical Waste (Kg) Waste Sharps (Kg) Other Infection Wastes (Kg)

Per Bed No. of

Beds

In house

Patients

Waste

OPD Total Per

Bed

No. of Beds Inhouse

Patients

Waste

OPD Total Per Bed No. of Beds In

house

Patients

Waste

OPD Total

1 National HCU 0.15 400 60 20 80 0.2 400 80 80 160 0.1 400 40 20 60

2 Regional Hospital 0.15 300 45 12 57 0.2 300 60 60 120 0.1 300 30 12 42

3 Provincial Hospital 0.15 100 15 4 19 0.2 100 20 20 40 0.1 100 10 4 14

4 District Hospital 0.15 50 5 2 7 0.2 50 10 5 15 0.1 50 5 2 7

5

Comprehensive Health

Centre 0 2 2 0 5 5 0 2 2

6 Basic Health Centre 0 1 1 0 4 4 0 1 1

7 SHC 0 1 1 0 2 2 0 1 1

8 Others(Incl.Pvt Hospitals) 0.15 30 4.5 2 6.5 0.2 30 6 4 10 0.1 30 3 2 5

Source: The HCWM report Estimate

Note: The estimate for the Anatomical Waste, sharps waste & other Infectious waste has been worked out on the basis of the field visits & discussions

with the stakeholders. The smaller HCFs such as BHC & SHC would primarily produce waste from the OPD activities and the sharps waste from the

Immunization drives.

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The HCWM Plan underlines the fact that the Incinerators have been installed at many

hospitals. However, many of this equipment are not operational owing to a number of factors

such as the following:

1) Lack of trained technicians required to operate the Incinerators

2) Maintenance issues

3) Lack of Funds for the fuel & other operational heads required for their smooth running.

4) Age of the Incinerators

Many of these Incinerators are low technology based, with only a single chamber, low

chimney height (3-4m), no temperature Indicators etc.

The MoPH plans to ensure the already-installed incinerators are made operative. Other option

is to build or De Montfort Incinerator using local material. Periodic air sampling is envisaged

to check the emission standards. The will be done by the third party the result of which will be

presented to the related authority. The other requisite measures include lying down of proper

maintenance procedures training of the technicians and signing of the Annual Maintenance

Contracts (AMCs) with the suppliers of Incinerators so adoption of some good practices with

respect to Incinerators would also ensure a better compliance with the HCWM policy. The

MoPH will undertake corrective measures for those Incinerators not properly located.

Similarly, the issue of disposal of ash from the incinerator will be appropriately addressed.

Disposal Site Analysis

A visit to the Gazak Landfill site revealed that presently the HCW mixed with the MSW is

being disposed off at the site. Aerobic composting of the organic fraction of the MSW is

undertaken. An area of 4000 sqm has been earmarked at the Gazak II landfill site for disposal

of HCW generated in Kabul.

Scavenging & Recycling

During the field visits to the hospitals, no major scavenging or rag pickers operations were

observed. This is probably due to the fact that the recycling industry based on the waste

generated in the healthcare facilities in Afghanistan is not organized; however, a few recycling

operation is going on. there are evidence of scavenging operations, but that is mostly for

municipal waste.

The proposed HCWM policy with focus on implementation of CWTFs in some pilot projects

would lead to generation of reasonable quantities of recyclable material, specially the

Disinfected & treated plastics. The economies of Scale provided by the large scale generation

of the recyclable plastics could be used as an incentive & impetus to the recycling industry,

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particularly when coupled with the implementation of Segregation of Municipal Solid Waste

at the Landfill site.

Training Needs Assessment

A broad TNA was carried out for Infection Prevention at the National, Provincial & Regional

Hospitals and the Smaller HCUs at the district level and rural areas. A similar analysis was

undertaken for TNA for HCWM at different levels of the Health Care Facilities.

The status of staff training in Infection Prevention based on a scale of non-existent (0) to very

high (5) among various parameters such as the awareness level, initial training and capacity

Building & Retraining as per the IP Policy of the MoPH has been presented in Table ??. A

distinct difference was observed in the status of Training of the staff working at the larger

hospitals and the smaller/rural HCUs.

A similar broad assessment was also made for the HCWM and it was found to be virtually

non-existent (0) to very low (1) in terms of different parameters.

Table 8: Training Needs Assessment

S. No. Policy Awareness

Level

Initial

Training

Capacity

building and

Re-training

1. Infection Prevention

(National, Provincial and

Regional Hospital)

Yes 4 3 1

2. Infection Prevention (District

Hospitals, Smaller HCUs)

Yes 2 2 0

3. Healthcare Waste

Management

(National, Provincial and

Regional Hospital)

No 1 0 0

4. Health Care Waste

Management (District

Hospitals, Smaller HCUs)

No 1 0 0

IV. Health Care Waste Management Plan

The expected outcome of SEHAT project is to contribute to a healthier population and increased

human capital by enhancing the use of a set of health nutrition and population services with

proven cost effectiveness in the country but this may also create adverse impact on environment

and on health if a proper Healthcare Waste Management System is not put in place. Possible

adverse environmental impacts are related to operation and are the following: (a) Disposal of

medical waste, e.g., sharps, human tissues, blood and laboratory waste; and, (b) Risk associated

with handling Health Care Wastes during operation. All these potential environmental impacts

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could be managed during the operation of the Health Care Facilities and hospitals if a proper

HCWMP is prepared and appropriately implemented.

Keeping in view the above fact, under the SEHAT project, a preliminary plan were prepared to

improve the existing Health Care Waste Management system in the country , focusing on

organizational and implementation arrangements, training and financial implications. The

Government of Afghanistan and the MoPH were committed to undertake a proper sectoral

assessment of HCWM and develop a comprehensive HCWMP within the first six months of

SEHAT implementation, which after approval by the WB would replace the current preliminary

HCWMP.

The objective of the preliminary HCWM Plan was to establish the following basic intervention

for health care waste management:

Develop/adopt and disseminate guidelines for the proper management of medical waste to

relevant stakeholders ;

Develop/ adapt and implement a training package for health workers on proper healthcare

waste management;

Increase public awareness and promote community participation in municipal solid waste

management (e.g. reuse, reduce and recycle);

Increase the number of health facility with incinerators or other environment friendly

technology /equipment

To monitor the performance and review the Waste Management Plan at least annually;

This comprehensive Health Care Waste Management Plan is developed based on what already

agreed in the Preliminary Health Care Waste Management Plan. Based on the work undertaken,

priority interventions for the health care waste management in Afghanistan include:

i) Development of a Manual & Guidelines along with compendium of best practices being

adopted in developed or developing countries on Health Care Waste Management and

dissemination of the same among the stakeholders, end users etc.

ii) Policy education and awareness

iii) Training of the Trainer and Exposure Visits of the Regulatory Authorities

iv) Formulation of Waste Committee at different levels, Determination of Role and

Responsibility

v) Evaluation & determination of technology

vi) Establishment of Common Treatment Facility as Pilot project

vii) Establishment of a new policy framework to facilitate the implementation of the prepared

HCWMP.

viii) Preparing the roadmap for ensuring the involvement of the different stakeholders in

implementation of the HCWMP.

Based on the situation analysis of HCWM in Afghanistan, the existing practices & status of the

major operations have been detailed to identify the gaps. Based on the identified gaps for

different operations the objectives for the HCWM plan have been worked out and the

corresponding plan activities for the major components have been highlighted in the adjoining

Table 9.

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Table 9: HCWM Plan Activities of Major Components

S.N Operations Existing Practices/Status Gap Objectives Plan Activities

1 Waste

Generation Waste Generation not monitored

primarily because of lack of

proper collection and segregation

Lack of

monitoring

,weighing &

record keeping of

HCW generated at

the HCF

Waste generation to be

monitored quantitatively as

well as qualitatively.

Extensive Reporting

System & procedures to be

put in place.

Daily reporting system

suggested for waste

quantification &

monitoring. Also

monthly & quarterly

reports.

2 Waste

Collection Waste Collected from the OT,

General Wards, OPD Lab etc,

gets mixed generally.

Apart from the sharps &

Placentas, most of the other

waste is collected

Needle-cutters/Hub –Cutters not

used generally

Improper

Inadequate

collection of

different streams

of HCW

Color-coded Bins for

different stream of HCW

i.e. Anatomical Waste,

General Waste & Sharps to

be provided.

Needle Cutters/Hub

Cutters to be used for

separating used plastic

syringes from needles

sharps

Different types of HCW

to be collected in color-

coded bags & bins as per

the HCWM Plan

3 Waste

Segregation General Waste, anatomical

waste, & other Infectious wastes

are normally collected separately

at the point of generation

Sharps (used AD syringes)

collected separately in yellow

Boxes, but end up getting mixed

during transportation.

Patients/Visitors in the wards

sometimes dump the general

waste in the bins near the

Nursing Stations

Improper

Segregation of the

Wastes and mixing

of the segregated

wastes during

collection &

transportation

Different types of HCW to

be segregated at source

through a clear-cut color

coding system.

Color –coded Bins to be

provide at appropriate

locations in the HCU.

No access to the

patients/visitors to the Bins

placed near the Nursing

Station and OT for

collection of Infectious

waste, Anatomical Waste

& Sharps.

Designated Color coding

system for bags, bins,

trolleys & secondary

storage planned

4 Color Coding Color-coding exists only as far

as usage of yellow Boxes for

used AD syringes and Black bins

for other wastes

No Color-Coding for Bags &

the trolleys in which wastes are

Inconsistency in

the color-coding

for different types

of HCW

Elaborate but

implementable Color-

coding mechanism

suggested for different

types of HCW

Consisted & Uniform

- Do -

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transported

The color-coding for different

types of HCW is not

consistent and used more as an

exception than as a rule

Lack of Consistency in color-coding

often results in different types of

HCW getting mixed

Color-Coding for Waste

Collection, Transportation,

Secondary Storage etc.

planned.

Consistent color –coding

for HCW collection,

segregation, transportation

to secondary storage &

secondary storage faculties

to usher in uniformity and

alienate the hazards of

mixing of the waste & thus

ensuring a better HCWM.

5 Waste

Transportation Primary Waste Transportation

10

in Bags Carried manually by

trolleys by the Hospital

Sanitation Workers

Secondary Transportation is

non-existent as the disposal takes

place inside the HCU primarily.

Unsafe Primary

and Secondary

Transportation

Primary Transportation in

Bags & Trolleys with the

same color-codes as the

waste collection Bins

Secondary Waste

Transportation in closed

vehicles carrying HCW

symbol and duly

authorized by

NEPA/Environmental

Health Department

Unform color coded

trolleys for primary

transportation of

segregated HCW and

Authorised vehicles for

secondary transportation

from Hospitals to the

Treatment/Disposal site

6 Training Most of the Doctors, Nurses &

Para-medical staffhave been

trained in Infection Prevention as

per the Country’s IP Policy

The training schedule & re-

training as per the IP Policy is

not followed.

Virtually no training is being

done on HCWM

Re-training as per

the IP policy is not

done. The

refresher training

is not provided as

per the schedule

proposed in the IP

Policy.

The IP training procedures

& schedules to be followed

strictly in accordance with

the IP policy.

Detailed Training Plan for

HCWM worked out

covering different

stakeholders

Training Manual to be

prepared on HCWM.

Special emphasis and a

detailed training plan

based on TNA provided

in the HCWMP

10 Primary Transportation is the transportation of the waste from the point of generation to the secondary storage area within the healthcare facilities; Secondary

Transportation is the process of moving wastes from the secondary storage areas to the Treatment/Disposal Site.

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7 Waste

Management

Committee

No Provision for a waste

Management committee at HCU

level

Focal Person for HCWM not

appointed in most of the HCUs

No Institutional

Mechanism to

monitor & record

the HCWM at the

HCU level

Detailed Action Plan&

Guidelines for forming

waste Management

Committees at the HCU

recommended.

Designated Focal Point for

HCWM at the HCU level

made essential.

Plan to include a

responsible broad based

WMC with a clearly

designated Focal Point

at the HCU Level for

HCWM

8 Secondary

Storage No proper provision for

Secondary Storage of HCW.

No timeframe earmarked for

Secondary storage of HCW

before its disposal.

Improper

Secondary Storage

and the maximum

time for

storage/frequency

of collection not

defined

The maximum timeframe

for Secondary Storage for

different types of HCW

specified.

Provision for a proper

secondary storage

system in the hospital

and maximum time of

48 hours earmarked for

transportation to the

treatment/ disposal site.

9 Treatment &

Waste Disposal No clear cut policy on HCW

treatment and disposal

HCW either burnt in ovens/single

chamber Incinerators or is buried

inside the compound

No disinfection equipment

such as

Microwave/Autoclaves/Shredder

s installed except a few hospitals

Lack of Policy for

HCWM measures

and low quality

equipment used

for treating HCW

Policy guidelines &

Implementation Plan for

HCWM including

treatment & disposal

suggested.

Usage of Double-chamber

Incinerator, Autoclaves and

shredder with guidelines

for disposal of Incinerator

ash

Policy framework on

CWTF recommended.

Plan to include

technology and

specifications of HCW

treatment equipment and

operational framework

for CWTF

10 Technology No Comparative evaluation of

various technologies for HCW

treatment has been or is being

done.

A low level of technology is

in use for HCWM e.g. Single

Chamber Incinerators ovens,

Drums, Cemented Kilns etc.

Low level of

technology in use

in the current

HCWM practices

Comparative evaluation

undertaken for alternate

technologies for different

types of HCW &

appropriate

recommendations made

Plan for technology

adaption in the local

context and for remote

areas also suggested

Appropriate technology

guidelines at various

levels of HCUs

including those for

remote areas included.

11 Equipment The equipment for HCW waste

collection, transportation,

Lack of

standardization

Plan for procurement,

Commissioning,

Standards for HCW

treatment equipment and

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treatment & disposal is of poor

quality with no clear set of

guidelines

Non-standardized equipment

is being used mostly.

and quality

specifications for

HCW treatment

Maintenance of the right

type of equipment

provided.

Broad standards for each

type of equipment to be

used in HCWM set &

documented

the broad procurement,

commissions &

maintenance plan to be

provided.

12 PPE The PPE such as gloves, goggles,

mask boots etc is used partially in

some of the hospitals.

The guidelines provided in the IP

Policy are also not followed in

general

No mechanism to monitor the

extend of usage of PPE

Guidelines for

PPE not fully

followed as laid

down in the IP

policy

Clear-cut guidelines on

usage of PPE by various

stakeholders in HCWM i.e.

Doctors, Nurses, Para-

medical Staff and

Sanitation workers

recommended

Strict adherence to the PPE

recommended in the IP

Policy recommended

Guidelines & Framework

for usage of PPE provided.

Plan to strengthen PPE

usage as per the IP

Policy as well as the

regular monitoring of

the same.

13 Monitoring &

Evaluation NoM&E mechanism for HCWM

is in place at HCU level M&E for HCWM recently

included the work Profile for

the NGOs under the SEHAT

project in the fresh bidding

process undertaken in 2013.

Lack of M&E

mechanism for

HCWM at the

HCU level

A definite M&E

framework for HCWM

recommended

M&E by Independent 3rd

Party recommended in

addition to the existing

structures

M&E framework to be

included in the Plan

with provision for 3rd

Party monitoring of

HCWM at Provincial &

National level

14 Action Plan No road map for implementing

HCWM Plan in Place at the

Central, Provincial or the HCU

level

Absence of a road-

map for

implementing

HCWMP

An Action Plan suggested

for implementing HCWM

at various levels

incorporating the time

schedule, Training Plan

and the costs

Action Plan with time

schedules, training, IEC

& financial costs to be

suggested

15 Finance No separate budget for financing

mechanism for HCWM provided

At the HCW level there is also no

budget for HCWM provided, not

even for operational costs such as

Fuel for the installed incinerator

No a separate

budget for HCWM

provided at the

HCU level.

Financing Mechanism with

Capital Expenditure

(Capex) and Operational

Expenditure (Opex over a

5 year period provided in

the HCWM Plan.

Financial estimated

Budgets for both Capital

Expenditure &

Operational Expenditure

for HCWM to be

provided in the Plan.

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Investments and Costs for

separate heads such as

Procurement of equipment,

Training, PPE,

Maintenance detailed.

16 PPP PPP in the Health Sector of

providing BPHS & EPHS

through NGOs has been a

success story by & large

However the same is not

replicated in the HCWM Sector

PPP in the HCWM

Sector not

operational

The scope of the NGOs

role to be enhanced in

training & capacity

building for HCWM

3rd party M&E for HCWM

proposed.

Special emphasis on a new

PPP model for CWTF,

proposed for HCWM.

PPP role in HCWM to be

strengthened with a new

CWTF model.

17 Personal

Hygiene &

Sanitation &

Pollution

Abatement

No major focus on Personal

Hygiene such as washing of

hands PPE etc.

Water Quality at HCU level

& Ambient Air Quality ( where

Incinerators used) is not

monitored

MoPH

construction

Guidelines for

HCUs not

followed

2) Monitoring of Water

Quality and Ambient

Air including HVAC

recommend as per

NEPA guidelines.

Develop new

construction guidelines

as well as Plan to

conform with the same

to be included.

18 Construction Construction Guidelines for

Hospital buildings exist at

MoPH, but are outdated and not

followed in practice

Need to

implement

stringently

2) Need to develop and

adhere to a new set of

construction

Guidelines

emphasized

Need to include in M&E

framework

19 Integrated

Holistic

Approach

Piecemeal approach to HCWM

observed at the HCU level as

well as at the Provincial,

Regional & National Levels

Holistic Integrated

approach not

followed for

HCWM

2) An Integrated

approach with an

inclusion of various

stakeholders in the

HCWM

recommended.

20 Capacity

Building of

Env. Health

Department,

MoPH& other

stakeholders

No Capacity Building exercise

undertaken Lack of capacity

among the various

stakeholders for

implementing

HCWMP

3) Specific actions such

as Exposure visit to

India. Orientation

Program on HCWM

for functional heads

of all departments of

Training and Capacity

Building,

Exposure/Orientation

visits planned under

HCWM Plan.

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45

MoPH and extensive

capacity Building

measures at the

Provincial level

recommended

21 Waste Water

Treatment Waste effluent generated from

healthcare facilities and join the

drainage without treatment

Absence onsite

waste treatment

system in HCFs

4) To treat the

wastewater effluent

generated from HCFs

before releasing to

drainage

Provision to have

wastewater testing,

onsite treatment,

categorization of

wastewater from

Medical wards,

Laboratories, OT,

General Area, OPD etc.

and Healthcare waste

management guidelines

and policy

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46

There are three basic operations involved in healthcare waste management i.e. Segregation,

collection & transportation and treatment and disposal. The standard operation guidelines are

already well documented and published at WHO website. The objective of compilation of

different guidelines is to provide a ready reference for the implementing agency/authority during

implementation of HCWM Plan.

a. Waste Segregation Guidelines

Waste Segregation is the process of separating different types of waste at the point of production

and keeping them isolated, so that collection of different types of waste become an easy and safe

affairs of waste handling operations from point of production to disposal of the treated waste.

This could be easily done by following recommended color codes(see Table 8).

Table 10: Recommended Color Codes

S.No. Yellow Bins and Bags Red Bins and Bags Black Bins

and Bags

White Puncture

proof containers

1. Human tissues, Body

parts, organs , sputum

Infectious Solid

Waste(Waste generated

from disposable items

other than the waste

sharps such as Tubing,

Hand-gloves, saline

bottles with IV Tubes,

catheters, glass,

intravenous sets etc.

Food articles Waste Sharps

(Needles, blades,

glass, scalpels etc.

that may cause

puncture and cuts

including both used

and unused sharps

2. Animal Tissues, organs,

body parts, carcasses,

bleeding parts, fluid,

blood and experimental

animals used in research,

discharge from

hospitals, animal houses.

Chemical

Waste(Chemicals used

in production of

biological toxins,

disinfectants,

Insecticides etc.)

Plastic bottles

for soft drinks,

juices etc.

3. Microbiological and

Biotechnology Waste

and other Laboratory

Waste(Waste from

clinical samples,

pathology, bio-

chemistry, hematology ,

blood-bank, lab cultures,

stocks or specimens of

microorganisms, live or

attenuated vaccines,

dishes used for transfer

of cultures etc)

Used Plastic syringes

after hub-cutting/needle-

cutting operations

Aluminum

and metal cans

used for food

and drinks

4. Discarded Medicines

and Cytotoxic Drugs

Paper and

Board

5. Soiled Waste(Items Other

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contaminated with blood

and body fluids

including cotton,

dressings ,soiled plaster-

carts, linen, bedding,

other materials

contaminated with

blood)

packaging

material

General Waste containers should be placed beside infectious waste containers helps in better

segregation. Color code of bins and bags should be maintained in uniform manner to avoid any

confusion. Proper Label and Symbols must be displayed on bins and bags as per the standard

guidelines of WHO. “Guidelines for the Safe Transport of Infectious Substances and

Diagnostic Specimens by WHO” is available on web for ready reference.

Apart from the color code for the health care waste, the following practices should be

adopted:

i) Residuals of the general health care waste should join the stream of domestic refuse or

municipal solid Waste for proper waste management

ii) Sharp should all be collected together, regardless of whether or not they are

contaminated. Containers should be puncture proof and fitted with covers. It should be

rigid and impermeable to contain not only the sharps but also any residual liquids from

syringes.

iii) Bags and containers for infectious waste should be marked with the international

infectious substance symbol.

iv) Cytotoxic waste, most of which is produce in major hospital or research facilities, should

be collected in leak proof and strong containers clearly marked “Cytotoxic Wastes”

v) Radioactive Waste should be segregated according to its physical form; solid & liquid

and according to its half-life or potency: Short –live and lived in especially marked

containers

b. Storage Guidelines

It is essential to have a designated storage location within the health care establishment. For

storage of healthcare waste the recommended color coding techniques needs to be practiced

thoroughly so that mix up of different kinds of wastes can be avoided. While earmarking and

selecting the storage areas for healthcare wastes the following guidelines should be followed up:

Storage: An impermeable, hard-standing floor with good drainage, and an adequate water

supply to clean and easy to disinfect;

Good lighting and at least passive ventilation and protection from the sun;

Storage area should not be situated proximate to fresh food stores or food preparation areas;

and

Supply of cleaning equipment, protective clothing, and waste bags or containers should be

located conveniently close to the storage area.

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It should also be ensured that storage times for healthcare waste (i.e. the delay between

production and treatment), unless a refrigerated storage room is available, should not exceed the

following:

Temperature Climate : 72 hours in winter

48 hours in summer

Warm Climate : 48 hours during the cool season

24 hours during the hot season

c. Collection & Transportation Guidelines

To define the collection system it is necessary to understand the basic steps of Health Care Waste

Management Handling System. The basic steps in Health care waste Management handling

evolves on Segregation, Collection & Transportation and Treatment and Disposal.

Collection System can be divided under:

Primary Collection: On-Site Collection(Within the Establishment)

Secondary Collection : Off-site Collection (to CWTFs)

Primary collection starts at the point of waste production. The major waste production points in a

typical healthcare Facility include Medical Wards, Labour Room, OT & Surgical Room,

Pharmaceutical Stores and Labs. The following needs to be practiced:

Nurses and Staff should ensure that waste bags are tightly closed or sealed when they are

about three-quarters full.

Light-gauge bags can be closed by tying the neck but heavier gauge bags would require

plastic sealing tag of the self-locking type. Bags should not be closed by stapling.

Sealed Sharp containers should not be placed in a labeled, yellow infectious health care

waste bags.

The frequency of the collection should be on room to room basis once in every shift and

an ideal time of collection should be the start of every shift.

Strictly followed and practiced the color code guidelines.

The collection practices should be designed in a manner that facilitate the movement of

waste from point of production to storage/ treatment point efficiently while minimizing

the risk of personnel.

Proper training should be given to the contractors or the hospital workers. The driver of

the vehicle should be knowledgeable of medical waste and the measures to be taken in

case of an accidental spillage.

On Site Transportation

Transportation of Waste within the HCFs could utilize wheeled trolleys, containers or carts that

are dedicated solely for the purpose.

The selection of on-site vehicle should be based on the following specifications

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1. Easy to load and unload

2. No Sharp Edges that could damage waste bags or containers during loading and unloading

and,

3. easy to clean

The sample vehicles for this purpose have been illustrated at Figure 2.

Figure 1: Sample Wheeled Vehicles (Source: WHO)

Off-Site Collection and Transportation of Health Care Waste: The healthcare Waste

generator should be responsible for safe packaging and adequate labeling of waste to be

transported off-site for treatment and disposal. Packaging and labeling should comply with the

guidelines for the Safe Transport of Infectious Substances and Diagnostic Specimens provided by

WHO. Figure 3 is symbol of International Infection Substance used to denote that vehicle is

carrying Healthcare waste or bio-hazardous waste.

It should be the responsibility of waste generator to ensure that waste are being treated and

disposed of properly as per the guidelines of Health Care Waste Management Plan and to the

authorized disposal facility.

The waste should be transported off-site only by the authorized or accredited transporter or carrier

by NEPA.

Special packaging requirements for off-site transport in general, the waste should be packaged

according to the recommendations provided in sealed bags or containers to prevent spilling

during handling and transportation. All waste bags or containers should be labeled with basic

information on their content and on the waste producer. This information may be written directly

on the bag or container or on preprinted labels, securely attached. For health care wastes, the

Figure 2: International Infection Substance Symbol

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following additional information should be marked on the label: waste category, date of

collection, place in hospital where produced (e.g. ward), and waste destination.

Any vehicle used to transport health care waste should fulfill the following design criteria:

The body of the vehicle

should be of a suitable size

commensurate with the

design of the vehicle, with

an internal body height of

2.2 meters.

There should be a bulkhead

between the driver’s cabin

and the vehicle body, which

is designed to retain the

load if the vehicle is

involved in a collision.

There should be a suitable

system for securing the load during transport.

Empty plastic bags, suitable protective clothing, cleaning equipment, tools, and

disinfectant, together with special kits for dealing with liquid spills, should be carried in a

separate compartment in the vehicle.

The internal finish of the vehicle should allow it to be steam cleaned, and the internal

angles should be rounded.

The vehicle should be marked with the name and address of the waste carrier.

The international hazard sign should be displayed on the vehicle or container as well as

an emergency telephone number.

Further based on different activities related to healthcare services, potential major impacts/issues

because of nature of wastes generated out of these activities, mitigation measures, indicators, cost

implication to initiate mitigation measures , responsibility for mitigation and supervision and

responsibility for monitoring have been worked out in Table 11.

Table 11: Health Care Waste Management guidelines (HCWMP) Matrix for SEHAT

Activities Potential

Major

Impacts/issues

Mitigation

Measures

Indicators Budges $

(Proposed)

Responsibility

for Mitigation

and supervision

Responsibility

for

Monitoring

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Antenatal

care

Immunization

Laboratory

test

Laboratory

waste, sharps,

syringes, poor

antenatal care.

Risk of

Infection

Sharps

should be

placed in

special

containers

and

properly

labeled

before

incineration

waste

disposal)

Implement

guidelines

and

followed

good health

care

practiced.

Not

significant

cost, this cost

will be

part of

implementing

NGOs budget

contracting

for delivery

of health

services

Implementing

NGOs/

Environmental

Health Dept.

GCMU/

Provincial

public health

directorate

third party/

M&E

department/JH

University

Delivery and

pre-natal

care.

Handling

human parts,

immunization

Risk of cross

infection if no

proper

handling of

waste

including

human parts,

waste water,

and sharps

disposables.

Contamination

of Soils &

groundwater.

Sharps

should be

placed in

special

containers

and

properly

labeled

before

incineration

waste

disposal

Human

parts should

be

disinfected

before

disposal.

Implement

guidelines

and

followed

good health

care

practiced.

Not

significant

cost, this cost

will be

part of

implementing

NGOs budget

contracting

for delivery

of health

services

Implementing

NGOs/

Environmental

Health Dept.

Provincial

public health

directorate

third part/

M&E

department/JH

University

Postnatal

Care

Immunization

Sharps,

disposables

Sharps

should be

placed in

special

containers

and

properly

labeled

before

incineration

waste

disposal

Implement

guidelines

and

followed

good health

care

practiced

Not

significant

cost, this cost

will be

part of

implementing

NGOs budget

contracting

for delivery

of health

services

Implementing

NGOs/

Environmental

Health Dept.

GCMU/

Provincial

public health

directorate

third part/

M&E

department/JH

University

Family

planning

Risk of cross

contamination,

Sharps

should be

Implement

guidelines

Not

Implementing

NGOs/

GCMU/

Provincial

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laboratory

test,

injections

sharps,

disposables

placed in

special

containers

and

Properly

labeled

before

incineration

waste

disposal

and

followed

good health

care

practiced.

significant

cost, this cost

will be

part of

implementing

NGOs budget

contracting

for delivery

of health

services

Environmental

Health Dept.

public health

directorate

third party/

M&E

department/JH

University

Care of the

newborn.

Immunization

Risk of

accidental

infection

through poor

handling of

sharps and

cross

infections

Sharps

should be

placed in

special

containers

and

properly

labeled

before

incineration

waste

disposal

Implement

guidelines

and

Followed

good health

care

practiced

Not

significant

cost, this cost

will be

part of

implementing

NGOs budget

contracting

for delivery

of health

services

Implementing

NGOs/

Environmental

Health Dept

GCMU/

Provincial

public health

directorate

third part/

M&E

department/JH

University

Storage of

Medical

Waste

Risk to

unauthorized

persons and

workers if not

in proper

receptacles,

and workers

not properly

protected.

Proper

handling

and storage

including

protective

gear

according to

HCWMP

Implement

guidelines

and

followed

good health

care

practiced.

Not

significant

cost, this cost

will be

part of

implementing

NGOs budget

contracting

for delivery

of health

services

Implementing

NGOs/

Environmental

Health Dept

GCMU/

Provincial

public health

directorate

third part/

M&E

department/JH

University

Transport of

waste to

disposal sites

Risk of spread

of diseases,

personnel

exposure to

disease and

bacteria

Collect

waste in

closed

containers

and

transport

waste in

specialized

closed

vehicles

Regular

supervision

of

transporters

potters,

verify the

use of

special

containers

for MW,

provide

Not

significant

cost, this cost

will be

part of

implementing

NGOs budget

contracting

for delivery

of health

Implementing

NGOs/

Environmental

Health Dept

GCMU/

Provincial

public health

directorate

third part/

M&E

department/JH

University

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training for

potters

services

Disposal at

site

Incinerator

Impact

(Smoke, flue

gas, lung

diseases)

Proper

siting of

well

construct,

Incinerators,

ash buried

in special

lined pits.

Implement

guidelines

and

followed

good health

care

practiced.

Not

significant

cost, this cost

will be

part of

implementing

NGOs budget

contracting

for delivery

of health

services

Implementing

NGOs/

Environmental

Health Dept

GCMU/

Provincial

public health

directorate

third part/

M&E

department/JH

University

Source: HCWM Preliminary Plan

d. End Disposal Plan for HCWM

End disposal of HCW according to the category/type of wastes can be decided using following

option..

Table 12: Categories of health-care waste and their final disposal decision matrix

Type of Waste Location In-situ

Treatment

End Treatment Final

Disposal

CWTF

CWTF No CWTF

Human tissue, body

parts and placenta`

OT, Labor

Rooms, Wards

Incineration at Common

treatment facility

Deep Burial

inside the

hospital

Incineration

ash to be

buried in

secured

landfill

Cotton, gauze

dressings, POPs soiled

with blood, pus and

other human discharges

All wards, OT,

Labor rooms, Lab

ICU, Acute

wards, Isolation

wards

Autoclave/Microwave

and shredding at

common treatment

facility

Landfilling

after

disinfection

and

converting

them into

pieces

All types of plastics,

i.e. plastic syringes, I.V

lines, I.V bottles, bags

All wards and

departments

Autoclave/microwave

and shredding at

common treatment

facility

Disinfection

and

mutilation

Formal

recycling

Discarded medicines

cytotoxic drugs and

heavy chemicals

Stores Incineration at common

treatment facility

Deep burial Secured

landfilling of

Incineration

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ash

Soiled Linen OT, labor rooms,

ICU, Isolation

wards, Acute

wards and other

wards

1%

Hypochlorite

solution for 30

minutes

Washed in laundry Washed in

laundry

Reused after

wash

General waste such as

leftover food in

patients plates,

stationery, fruit waste,

unsoiled dressings,

gauze and cotton from

Green bucket

All wards &

departments

Non treatment Municipal

sanitary

landfilling of

the general

waste

NA

Needles, blades All wards &

departments

1%

hypochlorite

for 30 minutes

Stored in Puncture Proof

Containers

Autoclaved

and stored in

Puncture

proof

containers

Formal

recycling after

disinfection

Microbiological

samples

Labs 5%

Hypochlorite

solution for 30

minutes

Autoclaving Autoclaving Liquid

discarded in

drainage

Liquid waste from

wards, departments and

autopsy room

All

wards/Autopsy

rooms

5%

Hypochlorite

for 30 minutes

- - Liquid

discarded in

drainage

Silver nitrate from X –

Ray dept.

X- Ray Dept. - - - Formal

recycling

Broken thermometers

and

sphygmomanometers

All wards &

departments

Collected

safely in

mercury spill

kits

- - Hazardous

land filling

Chemicals used in

production of

biological, used in

disinfection or as

insecticides

Hospital Stores - Send for incineration or

secured landfilling

- Send for

incineration

or secured

landfilling

Discarded expired

infected blood or its

products

Blood Bank 5%

hypochlorite

solution for 30

minutes

Autoclaved at common

treatment facility

Liquid

discarded in

drainage after

disinfection

Liquid

discarded in

drainage after

disinfection

Waste Stationery from

office

Office - Formal recycling Formal

Intact glass tubes, petri

dishes, empty glass

bottles

Lab. 5%

Hypochlorite

for 30 minutes

Autoclaved in CSSD Autoclaved in

CSSD

Recycled in

hospital

(Source: Mainstreaming Environmental Management in the Health Care Sector “Implementation

Experience in India & Tool-Kit for Managers, The World Bank)

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V. Organizational Arrangements for Implementation

A. National Level

The responsibility for ensuring the implementation of the HCWMP lies with the MoPH,

which is the implementing agency for the SEHAT. The overall responsibilities will be

with the Secretariat (MoPH). The specific responsibility will be of the Environmental

Health Department under the General Directorate of Preventive Medicine (GDoPM) of the

MoPH. It is important to note that Environmental Health Department and its designated

Focal Officer for HCWMP implementation will work in consultation with the GCMU on

the HCWM activities and act as focal points to ensure effective, successful

implementation of this HCWM plan.

The HCWM is multi-sectoral in nature and various stakeholders such as the MoPH, NGOs

providing BPHS and EPHS in the provinces, Provincial Hospitals, PPDs, National

Hospitals, NEPA, Municipalities, Donor Agencies, Private Sector etc. would require a

close coordination for effective implementation of HCWM Plan.

Institutional Capacity Building for Effective HCWM at National Level

The Institutional Capacity for HCWM in MoPH needs to be built up considerably for the

policy and the plan to be effective. The Environmental Health Department should be made

the nodal agency and the focal point for capacity building in the HCWM area in

Afghanistan at the National, Regional, Provincial and the rural levels.

The following measures are suggested to build the institutional capacity for HCWM in

MoPH:

o A Training-cum-Orientation Trip to the existing modern Common HCWM facilities

among the neighboring countries to be arranged which will provide the Environment

health staff and the Hospital Administrators with the requisite background

information and knowledge about the planning and operational aspects of integrated

waste management facility. This orientation trip will also provide the administrators

to analyze the viability of the PPP models and the user fees structure of some

successfully operating CWTFs.

o The key staff at the Environmental Health Department and the personnel from

Health Department at Provincial level should be encouraged to undertake

specialized courses/trainings in HCWM to update their knowledge and skills.

Suggested contents for the orientation and train- the- trainers program has been

later.

o Special focus must be given on building up a team of technicians for Operation and

Maintenance functions for the HCWM equipment. The endeavor should be to

develop capacity at the Regional level as well to ensure that the procured and

installed HCWM equipment is operative with a minimal downtime.

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o All key staff members at the MoPH including from the departments such as

Administration, Finance, Training, Procurement etc. must undergo a basic training

program in HCWM and the policy framework for the same. This will enable them to

get familiar with the HCWM concepts, policy framework, plans, procurement

schedules, training requirements, financial implications, relevance of the PPP

models etc.

o The monitoring and evaluation of the HCWM for the BPHS and EPHS service

providers at the provincial level must be entrusted to the respective NGOs. A

training program aimed at the capacity building of these NGOs on HCWM needs to

be developed and implemented.

o The above mentioned efforts need to be augmented by introducing a Train-the

Trainers program on HCWM. The major stakeholders such as the NGOs, EHD,

PPD, and Nursing Heads of major National, Regional and Provincial Hospitals

could be trained through this initiative and then they can train the relevant staff in

their respective institutions.

o A manual on formation and operation of the HCWM systems at the HCU level

needs to be prepared in Dari, Pashto and English by the MoPH in consultation with

the experts. The manual must focus on the HCWM policy, framework, Plan,

Methodology for formation and operation of a WMC at the HCU level, operational

parameters, meeting schedules, major issues, reporting systems, M&E Framework

etc. This would help to build the capacity at the HCU level to effectively implement

the HCWM policy.

The MoPH recognizes the importance of budget for Infection Control and HCWM is

allocated rather than the prevalent zero-cost approach among the health-sector

professionals, administrators and workers.

A Program for ensuring local availability of the spare parts for the HCWM Equipment as

well as the trained technicians will be implemented by the MoPH. The plant and

equipment suppliers for HCWM will be mandated to provide onsite training to the local

technicians during the installation and commissioning period and a minimum period of 6

operative months for the equipment.

B. Provincial Level:

At the provincial level, Provincial Health Directorate (PHD) and Implementing NGOs will

be responsible for the implementation of HCWMP. In the provinces, the provincial public

health directorate will assign monitoring Focal Point having proper ToR and will receive

needed training for effective implementation of the HCWMP.

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At the district level, Provincial Health Directorate (PHD) and Implementing NGOs will be

responsible for the implementation of HCWMP. At the health facilities, this responsibility

will lie with the Head of Health Facility.

Also, each major hospital supported by SEHAT project will have a HCWM Focal Officer

with proper ToR and will report to the Hospital Director/Manager/Sartabib11

. Meanwhile,

all healthcare workers will be trained and equipped to implement satisfactory infection

control practices and sound waste management.

Institutional Capacity Building for Effective HCWM at Provincial Level

Infection Control and Waste Management systems require detailed guidance and strategic

planning to enable related activities to be implemented in a relevant and structured

manner. Most Provinces do not have plans for implementation and monitoring, with the

focus being primarily on procurement of consumables and contractual arrangements with

outsourced agencies or service providers.

The success of the PPP in providing BPHS and EPHS in the provinces by the NGOs could

be a useful stepping stone for implementing HCWM across the country with Private

Sector Participation, especially for implementing CWTFs on pilot basis as well as the 3rd

party monitoring and evaluation of the HCWM on a regular basis.

The NGOs providing BPHS at the Provincial level should have an inbuilt system for

monitoring the HCWM status in the HCUs. This should be made an integral part of the

HMIS. The NGOs should also be responsible for monitoring & reporting on any major

incidents such as Needle stick Injuries, Shutdown of the Incinerators/other HCWM

equipment etc. through exception reports.

Figure 4 is illustration of Institutional Capacity Building needs to be carried out at various

levels to ensure proper implementation of HCWM plan as well as monitoring & evaluation

of HCWM system.

11Hospital Director is known as Sartabib in Dari language

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Figure 3 : Schematic Representation of Institutional Capacity building of various stakeholder for proper

implementation of HCWM plan

To implement the HCWM in a comprehensive systematic manner, the critical steps would be

to setup linkages between the top to bottom regulatory and HCWM plan implementing

body/agency (ies). It would also be necessary to list and clearly spell out the role and

responsibility of the different body/agency in implementation of the plan. The proposed

organization structure is illustrated at Figure 5.

Capacity building of MoPH

3rd

Party

(Monitoring &

Evaluation)

MoPH

PPU

Environment Health

Team for HCWM

Training

Provinces PPD

Provincial Nodal Officer

NGOs District

Hospitals

BHCs, PHCs &

CHCs

Focal Person for

HCWM at HCU Unit

Procurement of Equipment

and Services for HCWM

Waste

Management

Committee

General Directorate of

Preventive medicine

Environmental Health

Directorate

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Role of Different Stakeholders

The Role of different stakeholders in health-care waste management in Afghanistan have

been worked out & presented below:

Table 13: Role of different stakeholders in health care waste management Stakeholders

Leg

isla

tion

En

forc

emen

t

Po

lici

es a

nd

Gu

idel

ines

Ca

pa

city

Bu

ild

ing

Mo

nit

ori

ng

Res

earc

h a

nd

dev

elo

pm

ent

Ex

ecu

tin

g

Ag

ency

Fin

an

cin

g

an

d

Su

sta

ina

bil

ity

La

nd

All

oca

tio

n

Co

llec

tio

n

an

d D

isp

osa

l

NEPA Yes* Yes Yes Yes Yes Yes

MoPH Yes Yes Yes Yes Yes Yes Yes

Dept. Of

Environmental

Health

Yes Yes Yes Yes Yes Yes

Municipalities Yes Yes Yes Yes

WHO Yes Yes Yes Yes Yes

Multilateral

organization

Yes Yes Yes Yes Yes

NGOs and others Yes Yes Yes Yes

Health-care

Facilities

Yes Yes Yes Yes Yes Yes Yes

Centralized

Facilities and

Yes Yes

Private

Sector/Accreditation

Bodies

Yes Yes Yes Yes Yes Yes

Yes*: This refers to the active involvement of the organization/institution in the activity

specified in the column head.

The roles of the different stakeholders in the policy legislation, enforcement, capacity

building etc. have been worked out based on the interaction with the various organizations &

key personnel as well as the prevailing Healthcare Structures in Afghanistan.

Additional Regulatory guidelines to be issued

Based on the study of regulatory frameworks and policies available in Afghanistan pertaining

to HCW, the need to introduce some of the important guidelines by the relevant authorities

for better and effective management of HCW was highlighted. For instance Sanitary

Guidelines, User fees, Compact Fluorescent Lamps, Bidding & Procurement Policy etc..

Table 14: Additional regulatory guidelines

S.N Additional Regulatory Guidelines

to be issued

Government Departments

1. SANITATION GUIDELINES NEPA, Municipalities

2. User Fees PPP Deptt, MoPH

3. CFL Lamps Ministry of Energy

4. Bidding & Procurement PPP Deptt., MoPH, Private Transaction

Advisory Service Providers

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5. Ambient Air & Water Quality

Standards

NEPA, Afghan National Standards

Authority (ANSA)

6. Construction MoPH& Municipality

7. Infection Prevention MoPH

8. Specifications (Standards for HCW

Transport vehicles)

MoPH, NEPA, Transport Dept.

9. Mercury Spillage Control Standards MoPH, NEPA, Afghan National Standards

Authority (ANSA

10. Radioactive Wastes Disposal MoPH

11. Guidelines for CWTF MoPH, NEPA

Figure 4: Illustration of Proposed Organizational Chart.

Plan Implementation Schedule

Implementation of the HCWM Plan would include various activities including Public Consultation &

Finalization of the HCWM Plan, Exposure Visits, Training and Capacity Building, Standards for

Equipment, Procurement Policy framework, Regulatory Framework modification, Pilot Projects on

Deputy Minister for Health

Service Provision

General Directorate of

Preventive medicine

Environmental Health

Directorate

Radiation

Protection Wash Environmental

Hygiene Food

Safety Admin Training

Health Care Waste

Management

(Staffed with 7 Technical

Regional HCWM Officer

Provincial HCWM Officer

HCWM Focal Point at

each Hospital

HCWM Focal Point at

each BPHS Health

Faculties

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CWTF, Implementation of HCWM Plan at the HCU level, NGOs training, Integration with the HMIS,

M&E Framework implementation etc. The complete framework for the complete implementation of the

HCWM plan is expected to be about 2 years.

The overall implementation plan for HCWM in Afghanistan is illustrated at Figure 5. The proposed

Implementation Schedule for HCWM Plan has been detailed at Figure 6. The said plan is expected to be

implemented over a period of 24 months approximately.

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Figure 5: HCWM Implementation Plan

Public

Consultation

Finalisation of Policy

and HCWM Plan

Orientation

Program/Train- the

Trainers

Exposure Visit of a few

Major Stakeholders Training of NGOs,

PPDs, Other

Stakeholders

Detailed HCWM Plan

Regulation

Framework

Draft Policy

& Plan

Legislation, NEPA

Planning for Pilot

Project

Other Legislations, Bye-Laws &

Framework ( Water, Air, CWTF,

landfills Construction etc)

Procurement Policy ( Laying down

of relevant specifications)

Setting of equipment standards

Training & Capacity Building,

Manpower Resource

M&E Framework Implementation

PPP Framework

Tendering for Pilot

Project Implementation of Pilot

Project

Monitoring & Evaluation

By NGOs

By Independent

Agency

Review of HCWM

Plan and Course

correction if required

HCWM Implementation

Procurement

WMCs

Training

Linkages with CWTF (if

applicable) HCWM Plan for National,

Regional, Provincial Hospital

HCWM Plan for HCUs located in

Rural/far-flung areas

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Table 15: Proposed implementation schedule for HCWM Plan

Activities 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Finalization of the Plan Document

Acceptance by Stakeholders

Exposure Visit

Orientation/Training the Trainers’

Program

Standards for Bins, Equipment, PPEE

Vehicles, Burial Pits, Trolleys etc.

Procurement

Regulatory Framework

Pilot Project Planning & Implementation

including CWTFs, Landfill Sites, Storage,

Secondary Storage, PPE etc.

Implementation of HCWM Plan

Guidelines for Regional Hospitals &

Provincial Health Care Centre

NGO Training

HMIS

Pilot Project Roll Out

M&E Framework Implementation

including 3rd

party monitoring

The CWTFs proposed to be implemented as part of the HCWM should be implemented based on a PPP model with the Private operator managing the HCW treatment & disposal at the landfill site apart from secondary collection & transportation of the HCWM from the HCUs. The revenue model could be based on a fixed cost to the HCU on a per bed norm on daily basis. The PPP department of the MoPH should be made an important stakeholder in developing this model.

Month

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VI. Operational Framework

A. Introduction

This chapter includes an overview of operational guiding principles on the components related to

HCWMP. The purpose of this compilation is to have a single, first-level and easy-to-use

reference. These guidelines draw from a number of publications / websites of WHO and other

organizations.

The standardization of the current HCWM practices with the application of rigorous on-going

management and monitoring procedures, based on the Laws and National Guidelines.

Action Points for development of a comprehensive Healthcare Waste Management Plan include

the following:

A few key action points have been identified for implementing HCWM Plan

1) Formation of Waste Management Committee (WMC)comprising of Heads of the Hospital,

Nursing Superintendent, Doctor/Nurse from Infection Control Committee, Sanitary

Supervisor, Store-in Charge and supervisor of Housekeeping Staff

2) The designation of a Health-Care Waste Management Officer (HCWMO) who should be

given the responsibility to operate and monitor the management of the HCW on a daily

basis;

3) Standardized segregation procedures should be set-up in all

Afghan HCFs by implementing a three bins system that

should be systematically associated with a color coding, a

labeling system as well as minimizing procedures;

4) The development of specific treatment/disposal methods according to the type and the

location of the HCFs where the waste is generated.

5) Proper collection points/stores are needed to avoid the current stage dumping of the

medical wastes in the hospital compound where it is contaminating the air and the hospital

environment. (Table 3 above)

6) Feedback form from HCUs on Quantification & characterization of HCW as well as

existing status

7) Training Kit & Manual (Dari & English versions). A manual may be developed which

should be made available to the public and the end-user as a reference book for the

following:

Setting up of Waste management Committee, Factors to be considered for the selection of Technology

Color codes to be practiced

layout specifications for construction of Burial Pits

Safety guidelines to be followed

Manual for Symbols and Labels to be used, routes layout out etc.

Sharp Management Plan

The development of manual is already underway.

8) Orientation Program for all Major stakeholders

9) Setting Standards and specifications for Equipment

10) Regional, Provincial & HCU level plans

11) Exposure visit of Major stakeholders i.e. Environmental Health, PPP Divin. Major MoPH

Stakeholders i.e. Hospital Administrators

12) Pilot Project with Kabul Municipality

13) Train the Trainers program

14) NGOs training on HCWM and Monitoring & Evaluation

15) Bidding of Pilot Project with active involvement of PPP Division, MoPH

16) Procurement of Equipment

17) Plans for Building Ambient Air specs, Burial Pits, Drinking Water Quality, Chimney

Height for Incinerators with assistance from NEPA

18) Identification of Nodal persons/Focal Points at Provincial & HCU level

19) Formation of waste Management committee

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20) Specific Plans for HCUs location Remote Area/Rural Areas

21) Report on Feasibility of CWTFs & action plan

22) AMCs for the existing Incinerators and other HCWM equipment

23) Recruitment of an Independent Agency for 3rd party M&E of HCWM in each of the

Provinces

24) System for Approving/Registering Special Vehicles for carrying BMW.

25) Reporting Formats for HCWM at HCU level, Provincial level & the National Level

26) Roll-out Plan at the National, Regional & Provincial levels

27) Evaluate the impact of the HCWM Preparatory & Initial phase to develop the strategy for

the subsequent years

28) Training of the technicians handling HCWM equipment such as Incinerators, Autoclaves,

Microwaves and shredders

29) Training of the Focal Persons at the Provincial level responsible for planning &

implementing HCWM in the respective provinces.

The role and responsibility of Waste Management Committee, their functions etc. have been

illustrated at Annexure V.

B. Hospitals and health facility

HSCs/BHCs/CHCs

The operational framework and overall plan for healthcare waste at this level depends upon what

services are being offered and identification of types of waste and quantity of waste to be

generated from these facilities.

As per the revised BPHS Package, 2010/1389 the BHC is a facility offering primary outpatient

care, immunizations and Maternal and Newborn care. Services offered include antenatal,

delivery, and postpartum care; newborn Care ,nonpermanent contraceptive methods; routine

immunizations; integrated management of childhood illnesses; treatment of malaria and

tuberculosis, including DOTS; and identification, referral, and follow-up care for mental health

patients and persons with disabilities including awareness-raising.

The services of the BHC cover a population of about 15,000–30,000, depending on the local

geographic conditions and the population density. In circumstances where the population is very

isolated, the catchment population for a BHC can be less than 15,000. The minimal staffing

requirements for a BHC are a nurse, a community midwife, and two vaccinators. Depending upon

the scope of services provided and the workload of the BHC, up to two additional health care

workers may need to be added to perform well-defined tasks (e.g., supervision of community

health workers and

The CHC covers a catchment area of about 30,000–60,000 people and offers a wider range of

services than does the BHC. In addition to assisting normal deliveries, the CHC can handle

certain complications, grave cases of childhood illness, treatment of complicated cases of malaria,

and outpatient care for mental health patients. Persons with disabilities and persons requiring

physiotherapy services will be screened, given advice and referred to appropriate services in the

area. The facility usually has limited space for inpatient care, but has a laboratory. The staff of a

CHC is larger than that of a BHC; it includes both male and female doctors, male and female

nurses, midwives, one (male or female) psychosocial counsellor when mental health activities are

implemented, and laboratory and pharmacy technicians. Physiotherapists will visit CHCs on an

outreach basis from the district hospital.

Typical health care wastes to be generated from above health facilities include Sharps,

Pathological waste and potential infectious wastes. These can be further elaborated as Needles,

Scissors, Razors, Broken glass, Body tissue, Fetuses, Body fluids, etc. Dressings, PVC tubing,

Culture dishes, Test tubes, Vials, etc.

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The incinerator as a treatment and disposal technology is not viable as in absence of requisite

quantity of waste these become inoperative. The ideal approach would be that these wastes from

point of production would be segregated according to the color codes and anatomical wastes

would be buried inside the burial pit and sharps into sharp pit after shredding and autoclaving of

the same. The other general wastes (food etc.) needs to be linked with the MSW wastes. Wastes

such as plastic bags, piston, syringe barrel etc. may be sent for recycling after getting them

disinfected. Refer the Figure 6: illustrating the steps involved in this approach. Option II in

given in the figure can be adopted where CWTF is viable or located in nearby areas.

Figure 7 Schematic Diagram of HCWM Plan to be adopted at HSCs/BHCs/CHCs level

The guideline for construction of pits is provided at Annexure VI. This method is not new for

Afghanistan; this is already being practiced at some of the healthcare facility already doing this.

This method is also compliant with the Infection Prevention Control Act and Policy of the

country which clearly underlines and prohibits the burning of infectious wastes. A table,

containing evaluation of different technologies and factors to be considered while opting the

technology for health care waste management, is provided at Annexure VII.

C. Storage Facility

All health-care facilities would be required to have a clearly designated waste storage area. The

Waste storage area has to be well-ventilated, with adequate space to store infectious and non-

infectious waste, and secured from pilferage. The shortage of storage areas results in the mixture

of waste or creation of overflow which allows animals and scavengers easy access to infection

waste. Another area of concern is the storage of insecticide stocks for vector control activities at

primary healthcare facilities. This tends to be poor, with insecticides often being stored close to

pharmaceutical stocks or in village houses where spraying operations take place. The

responsibility to supervise the internal collection of wastes, their transportation, availability of

waste bags, protective clothing and collection carts and crews should be given to a designated

officer. i.e. In charge of HCWMO at the HCF.

The storage areas within the premises of the HCFs where no in-situ treatment & disposal is

recommended and are linked with the CWTF, a uniform color-coding for different types of HCW

needs to be followed as with the Bins, Bags & Trolleys to ensure uniformity & avoid confusion.

Shredder Autoclaving/

Microwave

Segregation of Waste

according to the color

codes

Sharp Pit

Burial Pit MSW Waste Carrier

Sharps

Anatomical

Wastes, Infectious

wastes

General Wastes

Health Facility

Option I

Option II

Common Waste

Treatment Facility Centre

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D. Infection Control

It is very important to note and recognize that infection control is the responsibility of all

healthcare professionals – doctors, nurses, pharmacists and others. Preventing nosocomial

infections requires a hygienic and sanitized environment and maintenance of good practices and

use of protective gear. Routine cleaning of the health facility is absolutely essential, as that will

keep the environment free from dust and soil.

Running water, soaps or antiseptic and facilities for drying without contamination, are required

for healthcare workers to maintain cleanliness at all times. As a general practice of maintaining

good hygiene, the floors of the healthcare facility should be first swabbed with a wet cloth, then

swept to remove grits to avoid dust carrying pathogens from rising into the air and, finally,

swabbed with a disinfectant solution. The swab cloth should be washed with detergent after every

use. Infected linen in the hospital should be carefully packed in plastic bags, taken to the washing

area, stored in bleach solution and then washed with the usual cleaning agents.

Spill Control

Spillage usually requires clean up only of the contaminated area. For spillage of infectious

material, however, it is important to determine the type of infectious agent; in some cases,

evacuation of the area may be necessary. Procedures for dealing with spillage should specify safe

handling operation and appropriate protective clothing. In case of skin and eye contact with

hazardous substance, there should be immediate decontamination. The exposed person should be

removed from the area of the incident for decontamination, generally with copious amounts of

water. Special attention should be paid to the eyes and any open wounds. In case of eye contact

with corrosive chemicals, the eyes should be irrigated continuously with clean water for 10-30

minutes; the entire face should be washed in a basin, with the eyes being continuously opened

and closed.

General Guidance for Spill control

a) Vacate and secure the area to prevent further exposure of other individuals.

b) Provide first aid and medical care to injured individual.

c) Inform the designated person (usually the waste management officer) who should

coordinate the necessary actions.

d) Determine the nature of the spill.

e) Provide adequate protective clothing to personnel involved in cleaning –up

f) Limit the spread of spill.

g) Vacate all people not involved in cleaning up of the spillage involves particularly

hazardous substance.

h) Neautralize or disinfect the spilled or contaminated material if indicated.

i) Collect all spilled and contaminated material (sharps should never be picked up by

hand; brushes and pans or other suitable tools should be used). Spilled material and

disposable contaminated items for cleaning should be placed in the appropriate waste

bags or containers.

j) Decontaminate or disinfect the area, wiping up with absorbent cloth. The cloth (or

other absorbent material) should be turned during the process, because this will spread

the contamination. Working from the least to the most contaminated part, with a

change of cloth at each stage should carry out the decontamination. Dry cloth should be

used in the case of liquid spillage; spillage of solids, cloth impregnated with water

(acidic, basic, or neutral as appropriate) should be used.

k) Decontaminate or disinfect any tools that were used.

l) Seek medical attention if exposure to hazardous material has occurred during the

operation.

E. Treatment and Disposal of Health Care Wastes

All HCFs should treat and dispose the medical waste as per Table 11.

All sharps in their puncture proof containers should be disposed in the sharps pit, which is

to be located within the premises of the HCF.

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Infected organic waste, after disinfection, should be taken to the onsite deep burial pits and

covered with a layer of lime and soil.

Infected recyclables such as plastics and metals should be first disinfected using bleach

solution and / or autoclaved before sent for recycling.

Collection of garbage / municipal solid waste, the general / communal waste – non-

infected - should be managed with Common municipal waste treatment facilities. Organic

waste such as kitchen waste and leaf fallings would be collected and transported with

common municipal solid waste and depart for windrow composting at the landfill site.

Recyclable material such as packaging material and paper should be sold to authorized

recyclers or to link with Municipal Wastes. Care must be taken to ensure that the

recyclable waste is not infected and kept separated from infectious wastes at all times.

All equipment used for bio-medical waste treatment should be periodically maintained. Both

preventive and corrective maintenance schedules and records should be retained in the HCF.

Activities undertaken to improve health services, especially in major health centers and hospitals

will inevitably create waste that is potentially hazardous. Health care wastes are typically more

hazardous that other types of wastes and are of concern in assessing proposed health care

improvement activities. To address these concerns, it is essential to put in place safe and reliable

methods for handling and proper disposal of HCW.

Health care waste includes all wastes generated in the delivery of health care services. WHO

(1999a) estimates that 75-90% of waste produced by HCF originates from non-risk or general

sources (e.g., janitorial, kitchens, administration) and is comparable to domestic waste. The

remaining 10-25% of HCWM is classified as hazardous and poses a variety of potential health

risks.

Table 16: General Waste Management Rules

Option Waste Category Treatment and

disposal

Current practices

1 Human anatomical waste ( human tissues, organs,

body parts)

Incineration/ deep

burial

Incineration/ deep

burial

2

Animal waste (animal tissues, organs, body parts

carcasses, bleeding parts, fluid, blood and

experimental animals used in research, waste

generated by veterinary hospitals colleges,

discharge from hospitals, animal houses)

Incineration/ deep

burial

Incineration/ deep

burial

3

Microbiology & Biotechnology waste (wastes

from laboratory cultures, stocks or specimens of

micro-organism live or attenuated vaccines,

human and animal cell culture used in research

and infectious agents from research and industrial

laboratories, wastes from production of biological,

toxins, dishes and devices used for transfer of

cultures)

Local autoclaving/

microwaving/

incineration

Local autoclaving/

incineration

4

Waste sharps (needles, syringes, scalpels, blades,

glass, etc. that may cause puncture and cuts. This

includes both used and unused sharps)

Disinfection (chemical

treatment/ autoclaving/

microwaving and

mutilation/ shredding)

Disinfection

(chemical

treatment/

autoclaving)

5

Discarded medicines and cytotoxic drugs (wastes

comprising of outdated, contaminated and

discarded medicines)

Incineration,

destruction and drugs

disposal in secured

landfills.

Incineration,

destruction and

drugs disposal in

secured landfills.

6

Solid waste (items contaminated with blood, and

body fluids including cotton, dressings, soiled

plaster casts, lines beddings, other material

contaminated with blood)

Incineration /

autoclaving/

microwaving

Incineration /

autoclaving

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7

Solid waste (wastes generated from disposable

items other than the waste sharps such as tubing,

catheters, intravenous sets. Etc)

Disinfection by

chemical treatment/

autoclaving/

microwaving and

mutilation shredding

Disinfection by

chemical

treatment/

autoclaving

8

Liquid waste (waste generated from laboratory

and washing, cleaning, house-keeping and

disinfecting activities)

Disinfection by

chemical treatment and

discharges into drains

Disinfection by

chemical treatment

and discharges into

drains

9 Incineration Ash (ash from incineration of any

bio-medical waste)

Disposal in municipal

landfill

deep burial in the

health facility

10

Chemical waste ( chemicals used in production of

biological, chemicals used in disinfection, as

insecticides, etc)

Chemical treatment and

discharge into drains

for liquids and secured

landfill for solids

NA

F. Segregation of Waste and Onsite Storage

Segregation of waste at source is a single most important step in bio-medical waste management. Once

bio-medical waste mixes with general waste, the waste management problem magnifies and becomes

unmanageable. It is critical that wastes be segregated at the point of generation itself. The following

Table-17 gives the segregation method that should be used for the various categories of waste. All waste

containers should be made of good quality plastics or other strong material. These should have smooth

inner and outer surfaces to avoid dirt / dust sticking in indentations. They should be lined with non-

chlorinated plastic liners and should be kept closed at all times. The onsite storage locations should be

properly planned and be made available. Ideally, these should be nearest to the point of generation. Where

potentially infected wastes are generated, 2% bleach solution (freshly prepared twice a day) should be put

in the waste container and the waste should be put in the container having this solution. The quantity of

waste in each of the waste containers should be weighed and a log should be maintained. This should be

done prior to evacuating the container into the final onsite disposal.

Table 17: SHC, BHCs, and CHCs’ Wastes

Type of Waste

generated

Waste management

method

Staff training Remarks

Sharps:

Needles

Scissors

Razors

Broken glass,

etc.

Segregation into

puncture-resistant

containers. Deep

burial.

Use training provided to

vaccinators as the basis for

staff handling this type of

waste.

Segregation into puncture-

resistant containers. Deep

burial.

Pathological waste:

Body tissue

Fetuses

Body fluids, etc.

Deep burial. Teach staff to dispose of

these materials immediately.

Will need designs for deep

burial pit covers that allow

these wastes to be easily

dumped

Potentially infectious waste, containers with blood products :

Dressings

PVC tubing

Culture dishes

Test tubes

Vials, etc.

Deposit into color-

coded bag.

Deep burial.

Make staff more aware of

the dangers of this kind of

waste and how to store these

materials

Little experience with

segregating and proper

disposal of these materials.

The waste from containers should be transported to the appropriate disposal points. All personnel

responsible for the waste containers should wear gloves, masks, aprons and proper footwear. The

personnel should wash their hands and feet with soap and disinfectant solution after every handling of

these containers. Cleaning (sweeping and swabbing) should be undertaken twice daily and all the waste

from the dust bins should be emptied twice a day. No infectious wastes should be stored beyond 24 hours.

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G. Transportation of health care Waste

Medical wastes have to be transported both within the health facility and from the facility to the final

disposal location. Properly designed carts, trolleys and other wheeled containers will be used for the

transportation of waste inside the facilities. Wheeled containers shall be so designed that they have no

sharp edges. Waste handlers must be provided with uniform, apron, boots, gloves, and masks, and these

should be worn when transporting the waste as described earlier.

H. Use and Disposal of Auto-Disable (AD) Syringes

The MoPH recommends that Auto-Disable (AD) syringes are to be used for immunization instead of

glass or disposable syringes. In parallel to introducing AD syringes, MoPH has also developed and

disseminated detailed user guidelines that outline steps that should be followed when using an AD syringe

and disposing of AD syringes. Table 1818 defines the steps to be followed for use and disposal of AD

syringes.

Table 18: Instruction for use of AD syringes

No. Steps/ Stages

1 Select the correct syringe for the vaccine to be administered

2 Check the packaging. Don’t use if the package is damaged, opened or expired.

3 Peel open or tear the package from the plunger side and remove the syringe by holding the plunger.

Discard the packaging into a black plastic bag.

4 Remove the needle cover/ cap and discard it into the black plastic bag. Do not move the plunger

until you are ready to fill the syringe with the vaccine and do not inject air into the vial as this will

lock the syringe

5 Take the appropriate vaccine vial, invert the vial, and insert the needle into the vial through the

rubber cap. Insert the needle such that the tip is within the level of the vaccine. If inserted behind

you may draw air bubble, which is very difficult to expel. Do not touch the needle or the rubber

cap) of the vial.

6 Pull the plunger back slowly to fill the syringe. The plunger will automatically stop when the

necessary dose of the vaccine has been drawn (0.1 or 0.5 ml) .do not draw air into the syringe. In

case air should accidentally enter the syringe. Follow these steps to remove the air bubbles:

(a) Remove the needle from the vial. Holding the syringe upright, tap the barrel to bring the bubbles

towards the tip of the syringe.

(b) Pull the plunger back to allow air to come in through the needle until it comes in contact with

the air bubble in the syringe barrel.

(c) Then carefully push the plunger to the dose mark ( 0,5 or 0.1 ml) thus expelling the air bubble

7 Clean appropriate injection site, if necessary with a wet swab and administer the vaccine

8 Push the plunger completely to deliver the dose till it gets locked.

9 Cut the hub of the syringe immediately after use with a hub-cutter that collects the sharps in a hard

white translucent plastic container. Do not recap the needle. Then collect the cut syringes in a red

plastic bag. The cut/destroyed syringes, barrels and needles must be disinfected at the designated

place and properly disposed off.

I. Reporting System

The practice of record keeping shall be a step towards achieving the goal of institutionalizing the

HCWM system internally wherein all necessary information shall be trapped at ward/unit level in the

hospital. This shall be subsequently consolidated by the waste management in-charge to prepare the

monthly report to be sent from the HCU at the provincial level. This practice of record keeping shall

also enable the hospital authority to meet up the legal requirements as per the new policy. The

tracing of different waste management activities shall also be possible if a proper system of record

keeping remains in vogue.

The record to be kept shall be of distinctly two types- one for keeping all records related to HW to be

generated within the HCU and the other to track performance of the scavenging contractor engaged

for the non-clinical (Sanitary and scavenging) services in the hospitals (wherever applicable).

Specific formats of registers have been developed for keeping both types of records which has been

discussed below:

a. Record Keeping by Hospital Staff

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Some records shall be maintained in specified registers to capture various information pertaining

to the HCWM at various locations within the hospital by the hospital staff. The salient features

about these registers and the responsibilities are given below:

i) Labelling of Bags

During collection of the bags from the bins, the bags shall be tied up at the neck and

labeled indicating the date of collection and name of ward/unit. The responsibility of this

lies with the attending nursing staff for each ward and assigned hospital staff for other

units. The labels shall be signed by the concerned staff.

ii) Waste Collection Records

In order to institutionalize the HCWM system at the ward and unit level, a waste

segregation register shall be maintained by the ward nurse or concerned hospital staff to

record the number of bags being generated from the units. Attending ward sister or staff (

for other units) shall enter the number of different colored bag in duplicate (carbon copy)

in the specified format, sign and send it to the In-charge, WMC. The In-charge shall

receive, countersign and keep the original for further entry and send back the duplicate

copy to the ward/unit for their records.

b. Waste Management Record

A register shall be maintained by the In-charge, WMC of the hospital to collect daily record of

aggregate number of colored bags collected from the wards and units. The WMC after receiving

the copies of the waste segregation registers from al the units shall consolidate the records to

calculate the total number of bags generated on that day.

This record shall be maintained on a daily basis and finally be consolidating at the end of the

month to prepare the monthly waste management report.

c. Waste Treatment Records

The operator of the waste autoclave shall maintain records of the usage of the autoclave

and submit the records to the WMC for consolidation. A register shall be maintained by

the operator in which the following records shall be maintained. Daily record of boiler

operation, treatment cycle details, usage of autoclavable bags, and number of bags

containing infectious plastic waste.

J. Common Waste Treatment Facilities Centre (CWTFs)

A common healthcare waste treatment facility is a set up where healthcare waste, generated from

a number of healthcare units, is imparted necessary treatment to reduce adverse effects that this

waste may pose. The treated waste finally is sent for disposal in a landfill for recycling purposes.

This as an option has already been legally introduced and successfully being operated in other

country like India.

The coverage Area for One CWTF may be allowed to cater up to 4000 beds at the approved rate

by the prescribed authority such as NEPA. However in an area where 4000 beds are not available

within a radius of 100 km, another CWTF may be allowed to cater the healthcare units situated

outside the said 100 km.

Pilot CWTF Projects in 6 major Towns i.e. Kabul, Mazar, Jalali, Heart, Kandhar, Ghazni) should

be taken up preferably on a PPP basis and the outcome and the impact of the same post –

implementation should be ascertained and corrective action if required should be taken for the

subsequent projects.

The guidelines and standards to be followed up while setting up CWTFs have been provided at

Annexure VIII.

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Awareness and Training

b. Awareness

Every province should plan and undertake general awareness raising activities for IMEP,

which should include all levels of healthcare facilities. All IMEP related awareness activities

should be fully integrated with those being undertaken under the other national health

programs.

Professional bodies like health promotion department of MoPH can be involved in enhancing

understanding and promoting good practices. At the health facilities, appropriately located

display of IEC materials is most effective in ensuring that workers follow segregation,

treatment and infection control practices.

Public Consultation is an important ingredient of any HCWM Plan. It is proposed to have

extensive public consultations at various levels with different stakeholders in Afghanistan

such as NGOs, Hospital, Administrators, Municipalities, Doctors and other medical staff,

elected representatives, community, relevant government ministries and departments. before

the proposed HCWM plan is taken up for implementation. It is also suggested that since the

“ownership” by the various stakeholders is an important criteria for its success, the HCWM

plan may be subjected to minor changes & modifications based on the feedback received

during the Public consultations while meeting the overall Environmental compliance criteria

and the world Bank Safeguards.

The capacity of the stakeholders to adopt the HCWM Plan would also be ascertained during

the Public Consultations and the training programs would be worked out accordingly. The

Public Consultation process would also help to create awareness among the stakeholders

including the Public at large which could be further augmented during the HCWM

implementation through the IEC material.

The proposed HCWM plan apart from being disseminated through the websites of MoPH and

The World Bank, must also be shared with all the participating NGOs and the concerned

PPDs, Municipalities, HCUs, NEPA etc. so that a direct feedback from various stakeholders

could be received. Based on the feedback and the comments, the final HCWM Plan within

the broad framework of the HCWM policy could be finalized before the Policy is taken up

for framing the regulations.

The other relevant guidelines, policy changes etc. required for implementing the HCWM plan

also be ascertained during the Public Consultation process.

c. Training

i) Capacity Building at Central and Provincial Levels

The reinforcement of the institutional capacity will be done at National and provincial

levels through specific technical training to support the HFs in implementing the new

HCWM policy.

The exposure to the new concepts such as CWTFs, Color- Coding, Sanitary Land

filling, Deep Burial Pits, New equipment as Double Chamber, Incinerator,

Autoclaves, and Shredders etc. need to be provided to the various stakeholders.

The PPHD will be responsible for training of its staff in HCWM plan implementation.

There are two modules for training modules – (i) train-the-trainer and (ii) regular on-

going training within the health facilities. The implementing NGOs will undertake a

needs identification to facilitate planning and allocation of budget for this activity. It is

envisaged that all health facilities under intervention areas of the SEHAT project have

officially recognized trained health personnel who will be responsible for health care

waste management. Existing awareness and training materials can be used to further

develop the skills for the sound management of health care wastes. These resources will

be available at MoPH and NGOs.

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a. Training of The Trainers (TOT) Program

An outline of train the trainers program should be in line with the following

table (Table 19).

Table 19: Training of the Trainers (TOT) Program

DAY 1

Inaugural SEHAT, BPHS, EPHS

Session 1 Introduction to HCW & HCWM

HCWM POLICY & PLAN

Organizational structures

Session 2 Infection Prevention

Policy

PPE

Lunch

Session 3 Waste Collection & Segregation

Color-Coding of Bins

Sharps Management

Location of Bins

Session 4 Waste Transportation & Secondary

Storage

Color-Coding of Boxes, PP Containers, Trolleys, VATs

etc.

DAY 2

Opening Remarks

Session 1 Waste Treatment

Disinfection

Autoclaving /Hydroclaving

Session 2 Waste Disposal

Ash from Incinerators

Disinfected Sharps waste

Disinfected other Infection Waste

General Waste

Session 3 Technologies and Equipment

Lunch

Session 4 Training

Waste Management Committee

Implementation Schedule

Reporting systems

Monitoring & Evaluation

Session 5 PPP

CWTF

Valedictory Session Feedback

Action Plan

Vote of Thanks

b. Regular On-Going Training Within The Health Facilities

Training of Healthcare Personnel

The training needs to be imparted to all health-care professionals on waste

management issues, not only to provide them with the core knowledge, skills and

attitude to effectively work for the implementation of proper waste management

but also to make them understand the importance of good waste management

practices within and outside the health-care facility. The role of different health-

care providers and common messages on proper waste management practices

should be communicated to health care workers.

Target Groups: o Health Care Facility managers and Administrative Staff responsible for

implementing regulations on health care waste management

o Medical Doctors

o Nurses and Assistant Nurses

o Cleaners, Porters, Housekeeping Staff and Waste handlers

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Contents of the Training Program for Healthcare Personnel

The training programs should contain broadly the following topics

o Hazards of Health-care Waste

o Infection Control Measures

o Healthcare Waste Management and Handling Policy in the country

o Waste Management Steps; Waste Collection, Segregation, Transportation,

Storage, Treatment and Disposal

o Liquid Waste Management

o Cleaning of Spills

o Principle of Waste Minimization

o Alternatives to hazardous chemicals

o Occupational Safety Issues

The information about the basic Health Care Waste Management system need also

be included in the program.

Training Package for each Target Group

The development of a training package should be suitable for the various types of

healthcare establishments including CHCs, PHCs etc. A classification of training

package can be made as under:

For Personnel providing Health Care

For Waste Handlers: Topics covered may include the best practices for waste

management, health hazards, on site transportation, storage, safety practices and

emergency response.

For Health Care Waste Management Operators: Training course should include:

i) Information on the risks associate with the handling of health care waste;

ii) Procedures for dealing with spillage and other accidents

iii) Correct use of Protective clothing

For Staff who transport the Waste: The purpose of training to these group is to enable

the staff to carry out all procedures for:

i) Handling, Loading and unloading of waste bags and containers

ii) Dealing with Spillage or accidents

iii) The use of Personal Protective Equipment (PPE) and ;

iv) Documentation and recording of health care waste, e.g. by means of consignment

note system to allow waste to be traced from the point of collection to the final

place of disposal.

For Treatment Plant Operators (TPOs): Arrangement of Training for the prospective

TPO should be made by healthcare establishments. The contents should be in line with

the following:

General operation of the treatment facility

Health, Safety, and environmental implications of treatment operations;

Technical procedures for plant operation

Emergency response, in case of equipment failures and alarms for example;

Maintenance of the plant and record keeping;

Surveillance of the quality of emissions and discharges, according to the

specifications

Training of health facility staff on HCWM is budgeted under component 1 of SEHAT for

health workers. The NGO (18 provinces) will have provisions in their contracts to

training the health facilities focal HCWM focal points. The MoPH-SM will train the

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Environment Health

Officers of province

District -1 Province/Regional

Hospital NGO District -2 NGO

Directorate of Env.

Health

BPHS & EPHS

Providers MOPH

heath facility HCWM focal points in 4 provinces. The resources for the training of

management level for the MoPH personal in the HCWM department as well as at the

provincial level will come from the second component of SEHAT. During first life of this

HCWMP (first 6 months) the training materials will be developed, the trainers will be

identified. Once the comprehensive HCWMP is developed after the first 6 months, the

actual trainings will start in a cascade manner. The trainers will be trained in Kabul both

among MoPH and NGO staff. Then these trainers will conduct training for the provincial

level HCMM focal points, who will in their turn train the HCWM focal points at health

facility level.

The Ministry of Public Health with the help of World Bank will have a South to South

Exchange visits and cooperation with the Health Ministry of India on the Health Care

Waste Management system creation in the Afghanistan. This program, SAR Health

Care Waste Management Knowledge Exchange (SSKE Visit), is funded by a trust

fund and will help the MoPH in Afghanistan to improve HCWM practices in the country.

VII. Monitoring

a. Internal

As a part of SEHAT, quarterly progress monitoring would be done at all levels, i.e. provincial

and health facilities. In turn, MoPH will have to submit quarterly progress monitoring reports

to the multilateral departments. These quarterly progress reports should include a collation /

aggregation of the data / information compiled in each health facility.

The review will cover the following:

Status of HCWMP implementation, positive outcomes and how to improve poor

performance

Training implementation and its effectiveness

Need for modifications to existing operational guidelines or introduction of new

guidelines

A set of monitoring indicators for implementation HCWM plan should be merged with

the existing M&E system

Currently Environment Health Officers of Province monitor and evaluate the waste

management practice at the Provincial level and at District level and at Local Level NGOs

play crucial rule in waste management in Afghanistan. Figure 9 is illustration of Existing

HCWM monitoring and Evaluation (M&E) framework in Afghanistan.

Figure 4: Existing HCWM- M&E Framework

Monitoring and evaluation of BPHS

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In order to effectively monitor and evaluate BPHS, the ministry focuses on results defined by

the Health and Nutrition Sector Strategy (HNSS) and Millennium Development Goals.

National targets have been defined in the HNSS to be achieved by 2013. However, specific

targets should be set at the provincial level based on the results of provincial household

surveys.

Information and reports produced by the MoPH, other ministries, and agencies that are used to

gather information on performance and implementation of BPHS include:

1. Health Management Information System (HMIS) providing information in facility-based

estimates for select process indicators;

2. National Health Services Performance Assessment providing information on process and

outcome indicators;

3. Census figures provided by the Central Statistics Office provide population estimates at

village, district, province and national levels;

4. Household surveys such as the Afghanistan Health Survey (AHS), Multiple Indicator

Cluster Surveys (MICS) and National Risk and Vulnerability Assessment (NRVA)

providing information on selected primary health and nutrition indicators at population

level;

5. Other special studies, like qualitative surveys, measurement of maternal mortality, etc.

b. External

Given the need to avoid self-evaluation by NGO, hospital managers, and MoPH program

managers, that could result in conflicts of interest, independent, third party evaluation will be

extensively used. This will allow the MoPH to hold NGO and hospital managers accountable

for tangible results. It will also allow all stakeholders to have an independent assessment of

progress in health service delivery.

The NGOs providing BPHS at the Provincial level should have an inbuilt system for

monitoring the HCWM status in the HCUs. This should be made an integral part of the HMIS.

The NGOs should also be responsible for monitoring & reporting on any major incidents such

as Needle stick Injuries, Shutdown of the Incinerators/other HCWM equipment etc. through

exception reports.

Monitoring will be undertaken by trained staff through 3rd

party monitoring of facilities under

the PPAs. Feedback on the performance of the waste management system will be provided at

facility, provincial, and national levels. The results of this monitoring will be used in the

formulation of the Action Plan for Management of Health Care Waste.

The project will support annual surveys of facilities delivering the BPHS to assess quality of

care, availability of inputs, staffing, supervision and waste management. This effort will build

on the successful experience with the “balanced scorecard” assessments that have provided

annual data on more than 630 health facilities nation-wide and form a rich source of

information on quality of care, availability of key inputs, and human resources.

The project will support annual hospital assessments in all public hospitals in the country.

MoPH has made great strides in having a well-functioning HMIS that provides near real time

data coming from the administrative recording and reporting system. Quarterly reports from

the national HMIS will be used by the project to assess progress and identify critical issues.

Table 20: List of Indicator for monitoring of HCWM

Indicator Baseline Target Data source

Proportion of health facility in

which safety boxes or closed

containers are being used properly

for disposal of used sharps

84.4 10 Point

increase

over

baseline

Third party

HFA

Proportion of health facility in 68.6 10 Point Third party

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which syringes are being disposed

of WITHOUT being recapped

increase

over

baseline

HFA

Proportion of health facility with

posted procedures for

decontamination procedure steps

61.7 10 Point

increase

over

baseline

Third party

HFA

Proportion of health facility with a

basin with a water source and soap

available in this room

65.6 15 Point

increase

over

baseline

Third party

HFA

Proportion of health facility in

which disinfectants are being used

64.2 16 Point

increase

over

baseline

Third party

HFA

Proportion of health facility in

which evidence that the incinerator

is being used regularly

68 12 Point

increase

over

baseline

Third party

HFA

Proportion of health facility that

disposable syringes are being used

for all injections

99.8 Maintain

the baseline

Third party

HFA

Proportion of health facility with

evidence that the sterilizer is being

used regularly

66.5 15 Point

increase

over

baseline

Third party

HFA

Key components of the HCWM need to be monitored

The Key components of the HCWM need to be monitored at regular intervals to ensure that the

HCWM Plan is being implemented effectively. The factors which need to be constantly

monitored at the HCU level are as follows:

o Formation of Waste Management Committee (WMC)

o Notification of the Focal Person for HCWM.

o Number of Training Programs organized on HCWM and the number of trainees

o Procurement & Consumables including PPE, Bins, Bags, Autoclaves, PP Containers

Trolleys etc.

o Enclosed Secondary Storage space for HCW within the premises

o Effective implementation of the color-coding for HCWM.

o Reporting systems for HCWM and Exception Reports

o Proper Sharps Management

o If located in Rural/Remote Area, provision for Deep Burial Bits as per the

specifications

o Immunization for Waste collectors.

o Compliance with the IP Protocol

o Segregation of General Waste from Biomedical Waste

o Segregation of different types of BMW e.g. Anatomical Waste, other Infections

waste and sharps waste.

o Proper primary collection and transportation of segregated BMW in closed Bags to

Secondary storage.

o Linkages with the CWTFs if treatment not being done insitu.

o If Incinerator is installed in the premises its location should be proper, the gaseous

emissions must meet the ambient air standards, the ash must be disposed off

properly

The third party monitoring being proposed under the HCWM Plan could address

these issues on a periodic basis. The ash from the incinerators should be disposed of

in the landfill site. In the smaller towns, rural areas and remote places where

incinerators are used the ash could be disposed of to the burial pit.

o Mechanism to have separated General Waste Collected by the Municipalities

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o If BMW is transported to a CWTF, it must be done in designated closed vehicles

carrying Bio-hazardous symbol & duly approved by NEPA/MoPH.

o The HCU building meets the construction guidelines of the MoPH

o The Sanitation & drinking water quality is of acceptable.

VIII. BUDGET

Phased Manufacturing Program

It is suggested that keeping in view the local domestic manufacturing capabilities, and the

volumes of the different equipment & products required under the HCWMP, adaptability to

different levels of technology etc. A time-bound Phased Manufacturing Program (PMP) is

implemented in a manner that there is a definite trend towards indigenization in a phased manner.

A proposed PMP for the major equipment & consumables to be procured under the HCWMP is

as follows (Table 21):

Table 21: Phase Manufacturing Program for the major Equipment & consumables

S. No. Item Indigenization/Local

Procurement Time

Frame

1. Safety Gears, Colored Bins & Bags, Trolleys, Sharps

Safety Boxes

5-6 Months

2. Construction of Deep Burial Pits & Secondary

Storage/VATS at HCUs

6-8 months

3. CWTF Construction & operation 9-12 month

4. Procurement of Incineration *, Autoclave * and

Shredders *

18-24 months

*The important controls, sensors, thermostats & instrumentation may continue to be imported

while the fabrication and final assembling may be indigenized within 2 years’ time frame.

Procurement Policy

A detailed Procurement Policy needs to be developed by the MoPH in consultations with the

other stakeholders and in conformity with the proposed HCWM Policy framework. The CWTF

model is proposed to be implemented on a PPP mode where Private Sector investment is

envisaged. However, the initial projects are expected to be Pilot Projects where funding has to

come from MoPH. The large & more expensive equipment could be procured at the

Regional/Provincial level.

A viable Procurement Policy decentralized purchase of PPE, Bins, Bags, Trolleys etc. at the HCU

level with clearly identified set of supplier, is required to be developed. The managing NGOs

would have to be properly apprised about this policy. A listing of specifications of the major

equipment including a list of the potential suppliers, both domestic & foreign, needs to be

developed and shared with all stakeholders.

The Procurement Plan should be dovetailed with the implementation of the HCWM Plan to

ensure that the equipment is in place when the proposed plan is being implemented at the ground

level.

The procedures for procurement also need to be developed. A separate document on the

Procurement Policies and Procedures to be used by all the stakeholders, need to be developed by

the time the HCWM plan is implemented.

Financing

There is a need to work out and implement innovative models for financing the HCWM plan and

operations in Afghanistan given the budgetary constraints of the Government. A PPP model with

active participation of the Private Sector in HCWM would go a long way in implementing an

effective HCWM Policy Framework and implementing projects at the ground level.

The concept of user fees needs to be incorporated in the PPP model to ensure sustainable

operations for the Private to invest in these projects. The Capex and the Opex for the project

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could be recouped through a user-fees mechanism in which the HCU can pay the operator on a

per bed basis .The revenue generated from the User-Fees over a period of time (15 years) could

offset the initial investment as well as the operating costs of the Private Operators while ensuring

an adequate return. This approach may become even more relevant in the case of CWTFs where

substantial investments and costs would be required as well as a high level of technical

competence and expertise on part of the private operator.

The user fees are expected to offset the financial requirements to sustain the HCWM plan in the

subsequent years.

A mode to develop a “User Fees” based on the “Polluter Pays” principle needs to be developed

for the HCUs using the facilities of a CWTF for the treatment of HCW treatment & disposal. The

daily user fees could be based on a fixed amount per bed basis and is likely to be in the range of

7-10 Afghanis.

The user fees would have to be paid by the HCU to the CWTF operator. A successful

demonstration of this model should be provided to the important stakeholders who will undertake

the exposure visits to the neighboring country.

COSTING

The costing of training and Capacity Building at various levels has been worked out as under:

1. Waste Management Committee

2. Doctors

3. Nurses and Para-Medical Staff.

4. Sanitation Workers

5. Administrators

The training cost likely to be occurred has been worked out at Table 22. These costs have been

worked out on the basis of average number of participants, duration of training, training module

etc.

For training and capacity building including IEC material requirement at various levels and

orientation program and TOT (Training of Trainers) have been worked out for Five years. Figure

10 is illustration of fund requirements for training and capacity buildings at various levels.

The wages and salaries of the technical & maintenance staff as well as the costs for 3rd

party

M&E of HCWM plan implementation have not been covered in the financial estimates.

Figure 5: Year wise Investment Required

0

500000

1000000

1500000

2000000

2500000

3000000

1st Year 2nd year 3rd Year 4th Year 5th Year

US$

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IEC Material

IEC material (POSTERS, DISPLAYS, STICKERS, BANNERS) play a major role in

disseminating the information and creating awareness among the various stakeholders and the

public at large.

The IEC material needs to be developed on the following subjects:

- Usage of PPE(Directed at the Nursing Staff, para-medical staff)

- Waste Segregation at source (For Nursing Staff and Para Medical staff)

- Safe Disposal of Sharps(For Nursing Staff and Para Medical Staff)

- Color-coding of different types of Wastes (For Doctors, Nurses, Para-Medical Staff,

Sanitation workers and the Public )

- IEC Material for public focusing on usage of Black Bins for General Waste

The IEC Material should be in Dari and Pashto and must be prominently DISPLAYED at

all relevant strategic points in the HCF.

The cost estimates of the designing & printing of the IEC material have been worked out &

presented in Table 22.

INVESTMENT REQUIREMENT FOR TECHNOLOGY UPGRADATION AND NEW

PROCUREMENTS

Based on the estimate of Healthcare waste generation in the country, it broad requirement of

technology and equipment for overall effective management of Health Care Waste in

Afghanistan has been worked out.

The proposed 6 nos. each of the incinerators, autoclave, plastic shredders as part of the pilot

projects for common waste treatment facilities in the six major provinces i.e. Kabul, Kandhar,

Balkh, Jalalabad, Herat and Ghazni would be funded under the SEHAT project in Phase I.

The subsequent CWTFs are proposed to be implemented by the private agencies under the PPP

mode based on the experience gained from the first six facilities. Therefore no separate funding

for the facilities proposed under the PPP arrangement have been provided for.

The following table (Table 22) illustrates the investment requirements during the next five years.

T

TOTAL FINANCIAL REQUIREMENTS FOR IMPLEMENTING HCWM

Total Financial Requirements for implementing the HCWM plan in Afghanistan over the five

year period could be summarized as under (Table 23).

Year Training, Capacity Building and

IEC (USD)

Investment Budget

(USD)

1st Year 990000 1631500

2nd Year 885000 2603000 3rd Year 615000 2523000

4th Year 635000 1814000

5th Year 595000 1325000

G. Total 3,720,000 9,896,500

Name Nos Unit Price

(USD$)

Incinerators (25kg/hr) 6 50000

Autoclaves/Microwave (15 kg/hr) 6 20000

Plastic Shredding (15kg/hr) 6 10000

Deep Burial Pits 25 500

Sanitary Landfilling *

LS

Puncture Proof Bag 200000 2

Bins 12000 10

Bags 200000 1

Trolleys 2000 50

Vehicles 20 15000

Building & Construction 6 1500

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Table 22: Estimate of Financial Requirement for Training, Capacity Building and IEC (US Dollar)

S.N

1st Year 2nd Year 3rd Year 4th Year 5th Year

No. of

Program

Cost Total No. of

Program

Cost Total No. of

Program

Cost Total No. of

Program

Cost Total No. of

Program

Cost

Total

1 Orientation

Program and

training the

trainers (incl.

NGO)

4 20000 80000 2 20000 40000 2 20000 40000 0

2 Provincial

Level Training

70 5000 350000 35 5000 175000 35 5000 175000 35 5000 175000 35 5000 175000

3 District Level

Training

100 2000 200000 100 2000 200000 100 2000 200000 100 2000 200000 100 2000 200000

4 MoPH

Capacity

Building

2 20000 40000 1 20000 20000 1 20000 20000 0 0

5 PHCs and

HSCs HSCs

0 200 1000 200000 200 1000 200000 200 1000 200000 200 1000 200000

6 Training

Manual

Lump sum 20000 20000 0 0 0

7 Familiarization

Site Visits

1 200000 200000 1 200000 200000 0 0 0

8 IEC 50000 2 100000 25000 2 50000 10000 2 20000 10000 2 20000 10000 2 20000

Grand Total 990000

885000

615000

635000

595000

Note: Four Orientations cum Train-the-trainer programs are planned in the initial phase. Similarly the Provincial level training programs (app. 2 per Provinces in the 1st year) have been

planned coupled with Decentralized District level Training programs for the Smaller HCFs. Two programs to orient the various departments of the MoPH on the HCWM Concepts and

Plan Implementation are also proposed. Familiarization visits for the major stakeholders for the existing facilities in the neighboring countries in the 1st, and 2

nd year are also planned.

Table 23: Estimate of Financial Requirement for Technology Up-gradation and new Procurement (US Dollar)

S.

1st Year 2nd Year 3rd Year 4th Year 5th Year

No.s Unit No.s Unit Amoun No.s Unit Amoun No.s Unit Amoun No.s Unit Amoun

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82

N Price Amoun

t

Price t Price t Price t Price t

1

Incinerators

(25kg/hr) 6 50000 300000 12 50000 600000 12 50000 600000 6 50000 300000 0

2

Autoclaves/Microw

ave (15 kg/hr) 6 20000 120000 12 20000 240000 12 20000 240000 6 20000 120000 0

3

Plastic Shredding

(15kg/hr) 6 10000 60000 19 10000 190000 12 10000 120000 6 10000 60000 0

4 Deep Burial Pits 25 500 12500 50 500 25000 50 500 25000 50 500 25000 50 500 25000

5

Sanitary Landfilling

* LS 10000 LS 10000 10000 0 0 0

6 Puncture Proof Bag

20000

0 2 400000

40000

0 2 800000

40000

0 2 800000

40000

0 2 800000

40000

0 2 800000

7 Bins 12000 10 120000 12000 10 120000 12000 10 120000 20000 10 200000 20000 10 200000

8 Bags

20000

0 1 200000

20000

0 1 200000

20000

0 1 200000

20000

0 1 200000

20000

0 1 200000

9 Trolleys 2000 50 100000 2000 50 100000 2000 50 100000 2000 50 100000 2000 50 100000

10 Vehicles 20 15000 300000 20 15000 300000 20 15000 300000 0 0

11

Building &

Construction 6 1500 9000 12 1500 18000 12 1500 18000 6 1500 9000 0

Total 163150

0

260300

0

252300

0

181400

0

132500

0

Note: 6 Pilot Projects for CWTF (Comprising of Incinerator, Autoclave/Microwave and Plastic Shredders) are proposed to be implemented in the 1st year. The estimate, for the burial pits

is based n the HCWM requirements of those HCFs which would not have access to the CWTFs. The estimate for Bins, Bass, Trolleys and Vehicles (for transport of HCW from HCFs to

the CWTFs) is based on the broad requirements per facility.

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Disclosure

This preliminary Health Care Waste Management Plan was developed by the MoPH on the basis of review of

existing practices in the sector. Prior to approval of the SEHAT project by the World Bank, the preliminary

HCWMP was disclosed on November 28, 2012 by MoPH in Afghanistan on the MoPH website, Libraries,

HQ and provincial offices, MoPH implementing partners offices and by the WB Infoshop.

This comprehensive HCWMP is developed based on the recommendation of preliminary HCWMP which

would be cleared by NEPA and The World Bank before the complete disclosure of the same is made on the

relevant websites and public discussions with all stakeholders are completed.

The HCWMP after the Public Disclosure and approval of the stakeholders would be made operational.

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ANNEXURE I: MAJOR SCOPE OF WORK

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Annexure II

THE MAJOR SCOPE OF WORK FOR THE COSULTANT

Task 1: Assessment of Existing Policies and Waste Management Practices

i) Assess the policy legal and administrative framework as well as the regulatory

framework on health-care waste management and treatment in the country. This

includes air emission standards, which are currently required by law for the next ten

years.

ii) Identify permit requirements including environmental building and the other

procedures that healthcare waste management facilities would need to address and the

time demands to obtain these permits. In this respect, identify the environmental

impact requirements and public participation requirements.

iii) Assess the health-care waste generation at randomly selected facilities. The details

should include the minimum weight of total generated wastes at each health-care

facility per week. Composition of the waste should be determined through segregation

at the waste end point and the results should be extrapolated to cover the entire

country.

iv) Review and analyze existing health-care waste storage, collection and disposal system

at the randomly selected facilities with due regard for level of separation, frequency of

collection and environmental –through soil, surface and ground water and air

resources- and health impacts for existing treatment.

v) Assess the level of scavenging, if any, or recycling taking place inside health-care

facilities, along transportation routes, and at final sites. Determine social issues in

relation to scavenging taking place.

Task 2: Determination of Technology and Siting

a) Determination of Technology

For the types and quantities of health-care waste generated in the study, assess the

different types of technology and facility sizes available for treatment and destruction. The

assessment shall compare alternatives on the basis of capital cost, operation cost, ease of

operation, local availability of spare parts, local availability of operation skills,

demonstrated reliability, durability and environmental impact. The technologies to be

considered include; burial pits for safe land filling, incineration, sterilization (autoclave

and microwave) and chemical disinfections. On the basis of this assessment, recommend a

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process flow for economic and environmentally sound treatment and final disposal of

health-care waste.

b) Determination of Disposal Sites Analysis of the Site

Analyze the above information to determine whether there is sufficient appropriate

material on site for daily and final cover, and whether the soil, hydrological and geo-

hydrological conditions would ensure adequate protection of any ground and surface water

used for drinking and/or irrigation. If the sites prove to be unsuitable, inform the client

stating the reasons.

c) Financing

Assess alternative approaches for financing the treatment and disposal activities. Assess

public-private partnerships and cost recovery at the regional, municipal level based on the

polluter pays principal, where each health facility pays according to the volume of waste

generated. Assess private sector participation as service provider.

d) Public Consultation

Public consultation with beneficiary groups, institutions, NGOs and Community Based

Organizations and other interested parties be held as part

Task 3: Training and Public Awareness

i. At the randomly selected facilities surveyed as part of Task 1, assess awareness of

health workers of safety risks, correct procedures for collecting, handling and disposing

of health-care wastes.

ii. Review existing training and public awareness program on health-care waste

management at hospitals and other health-care establishments and prepare training

needs assessment.

iii. Working in conjunction with relevant government institutions and municipal councils,

prepare a costed training program targeting the general public, health-care workers,

municipal workers, dump site managers, incinerator operators (if that is the choice of

technology), nurses, scavengers/pickers, families and street children.

iv. The design of the material required for the awareness/capacity building programs

should be discussed with the relevant authorities and the general public to ensure that

their concerns that are deemed appropriate are incorporated in the design of the

program, sitting layouts, mitigation measures and community communication

programs.

v. It is understood that some of these training materials should be developed later on

during the implementation of the project.

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vi. Assess the institutional capacity of HCWM in the MOPH and make recommendations

so that MOPH take care of the implementation of the HCWM appropriately.

Task 4: Public Consultation and draft policy, Plan and Training Program

The training and awareness building program and the waste management program shall be

appropriately costed and the plan of action shall be presented in a national workshop.

Following the stakeholder consultations, the consultant(s) shall revise the draft reports in

accordance with the comments of the Government, WHO, The World Bank, and other

relevant institutions in the donor community and other interested parties and submit the final

report incorporating all changes and modifications as required. The Consultant is expected to

provide the report with pictures and maps where necessary to the government and the Bank.

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ANNEXURE II: COPY OF THE QUESTIONNAIRES USED

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Annexure III

QUESTIONNAIRE FOR HEALTH FACILITIES

1. Name & Address of the : Hospital/Healthcare center

2. Type of Healthcare Centre :

3. Name & Designation of : Responding Person

4. Population of City/Town :

5. No. of Beds in Hospital – what is occupancy rate? How many OPD patients on an average?

6. What kind of care is primarily provided – e.g. immunization, deliveries, HIV, TB, Minor Surgeries, OPD etc.

7. Are you aware of the HCWM concept and the Policy? Is your facility in compliance? Have you received all the necessary clearances for implementing the policy?

8. What steps have been undertaken to improve the HCW Management in your Healthcare facility l? How has HCW Management progressed over time with the implementation of the various Government‘s initiative in the Health Sector?

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9. What is the quantity and mode of disposal of different types of wastes generated at your hospital?

S No.

Nature of Waste Quantity Generated

Per Day

Method of

Treatment/

Disposal

1

Outdated Drugs, Chemicals and

disinfectants used in Labs & for

Decontamination of Needles

etc.

2

Syringes, Conules,

Catheters, (Infectious Plastics)

3

Pathological and anatomical

Waste, Infectious Waste,

Infected Blood, Cytotoxic

waste, etc.

4

Glass Waste (both broken

and non-broken)

5

Needles, Blades and Scalpels

10. Do you use reusable syringes? Do you have sterilization equipment in place?

11. What is the mode of collection and transportation of different types of waste generated at the Healthcare Unit?

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12. Is there any color-coding used being for collection of different types of wastes? Please elaborate.

Type of Waste Color of Container

and markings

Type of container

Highly Infectious

Waste

Red Strong Leak-proof plastic bag or

container capable of being

autoclaved

Other infection waste,

pathological and

anatomical waste

Yellow Leak-proof plastic bag or

container

Sharps Yellow, marked

“SHARPS”

Puncture-proof container

Chemical and

Pharmaceutical waste

Brown Plastic bag or container

Radioactive Waste - Lead box, labeled with the

radioactive symbol

General Healthcare

waste

Black Plastic bag

13. Are these consumables expensive?

14. Are they provided under the project or do they acquire them using user fees?

15. How will this be sustained after project life?

16. Have you come up with any innovative ideas for collection?

17. Is there any wastage (e.g. small volumes in large bags etc.)?

18. Are you using chlorinated plastic bags? Or are they non-chlorinated and if so are the costs higher?

19. What is the durability of the bins provided under the project? Please elaborate.

20. Do you have in-house facilities for treatment of infectious wastes & other wastes? If yes, please give details.

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21. In case you are using incinerator at your premises, please provide details on the equipment used & its technical features.

22. How is the residue from the incinerators disposed off?

23. Do you experience any difficulty in the operation and maintenance of the equipment installed at the hospital for HCW treatment (e.g. Autoclaves, incinerator, and Microwave equipment)? Please give complete details

24. What is the durability of the equipment provided under the project?

25. What is the better technology between hydroclaves, microwaves and autoclaves?

26. Do you have deep burial pits for final disposal?

27. Is there a recycling system in place for the plastics and glass?

28. How durable are the needle cutters/destroyers?

29. Are they being effectively used in all wards?

30. If No, are your using external facilities such as Common Waste Treatment Facilities (CWTFs) for treatment & disposal of waste?

31. How is the HCW transported to the CWTF?

32. What are charges per ton of HCW paid to CWTF?

33. What is the average quantity of HCW sent to CWTF for treatment? Please Elucidate.

34. What is the level of awareness and training provided to the different levels of staff for better HCW management in the hospital?

35. How often has training been provided? Is there ongoing refresher training?

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Type

Level

General

Ongoing

Awareness

Refresher

Training

About

HCWM

Frequency

Doctors

Nurses

Technician

Sanitary &

Lower Level

Staff

36. Who monitors the effective implementation at each facility?

37. How often does the HCWM Team meet?

38. What do they discuss and evaluate?

39. Who is in charge of daily operations?

40. Did you experience any difficulty in obtaining clearances/assistance from the regulatory bodies? Please elaborate.

41. Did you receive adequate assistance from the Ministry of Public Health/Project Management Unit?

42. Have any guidelines/plans been provided to you by the Government?

43. What has been the attitude of the community /NGOs/people at large?

44. Have they contributed towards achieving better HCW Management at the Hospital?

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45. Are you aware of the environmental and health implications of HCWM?

46. Which major difficulties/constraints have you faced in implementing better HCW Management Systems at the hospital?

47. Which are the critical issues (Both External & Internal) ?

48. Which determine the success of a HCW Management System? Please elaborate.

49. Which are the 3-4 major actions you have taken to improve the HCW management at the Facility?

50. Are any External Agencies such as Independent M&E organizations and/or NGOs who are working with you? Please provide details

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Islamic Republic Of Afghanistan

Ministry Of Public health

Preventive Medicine General Directorate

Environmental Health Directorate

HCW Disposal Project

HCW Disposal Standards

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Name of Province-------------- Name of Health Facility----------------- No Of Beds------- Catchment area population-----------------

-----------

Assess # 1-2-3-4-5, Date of Assess ---------------- Assess Team------------------------- No of Delivery/ Operation / Month------------

-----------

Comments 1 0 Standards/ Sub Standards Standard

/ Sub

Standard

#

Total: I: - Hospital has a HCW disposal committee or HCW disposal team incorporated as part of infection

prevention ToR.

Committee consists of key members of hospital departments ( Hospital director

or deputy, in charge and head nurse, Gyn/Obs, surgery, internal medicine chiefs,

OT nurse, and hospital admin)

1.1

One person selected as focal point for HCW among committee members 1.2

Written and signed ToR exist for committee which explains the responsibilities 1.3

Committee has regular meetings( weekly, bi weekly, or monthly as per need)

please refer to minutes of the meeting 1.4

Committee has work plan mentioning gaps, interventions, responsible person,

and end date of action 1.5

Total: II:- Committee members have received HCW disposal training

HCW Disposal training conducted for members of the committee 2.1

The training covers waste segregation, collection, storage, transportation,

treatment, accident and spillage. The training consists of theory and practical

stations

2.2

There is an action plan development at the end of training (cascade of training

and change of knowledge into practices) 2.3

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Comments 1 0 Standards/ Sub Standards Standard

/ Sub

Standard

#

Trainings adapt and conduct for different level according to level of knowledge

and understanding 2.4

HCW disposal included in list of hospital conferences 2.5

Total: III:- There is designated place and equipment for HCW disposal in health facility

Personal Protection Equipment (PPE) exists adequately for OT, dressing

room, delivery room, Lab, and other wards (caps , masks, safety eye glasses,

aprons and boots)

3.1

Plastic bags with the same color coding as the bins exist in wards, OT, dressing

room, delivery room, corridor and compound 3.2

Safety box exists in delivery room, OT, nursing and midwives room ( Not

accessible to the patients and their companions) 3.3

There is special place for the temporary storage of HCW in the health facility 3.4

The storage area is surrounded by wall or wire with lockable door,is out of the

reach of the children, animals and irresponsible persons with clear written and

pictorial alert signs

3.5

Total: IV:- HCW segregation exists in health facility

Red bin with red plastic for anatomical and pathological bio HCW

(dressing, placenta, part of body, lab waste)

Yellow bin and plastic for other infectious HCW (empty bottle of serum,

syrup, vial, used syringe, etc.

Black bin with black plastic for general waste ( food, dust, recyclables )

4.1

Doctors, nurses and people who deal with HCW, segregate the HCW at the

production site into hazardous and non-infectious 4.2

Sharps (Needle, surgical blade, suture needle, broken ampules put into safety

box. 4.3

Seal the plastic bag before transportation 4.4

Plastics will transport to incinerator, land fill, burial and laundry room 4.5

Total: V:- HCW collection is available in the health facility

Bins will evacuate when 3/4th

filled or at the end of the day, after each delivery

or operation 5.6

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Comments 1 0 Standards/ Sub Standards Standard

/ Sub

Standard

#

The sealed waste plastic labeled with date of production, place and the contents 5.2

Change the plastic of bin after r emoval of waste 5.3

Wash the bin after exchange of old plastic into new plastic 5.4

The is pictorial guide close to each bin which help the patient and accompanies

in segregation of HCW 5.5

Total: IV:- HCW storage system is available in health facility

HCW is transporting before 24 hours from storage area( HCW should store

between 3-8⁰ )be 6.1

The land fill is cleaning regularly 6.2

The container which has chemical waste should store in separate room 6.3

The health facility is not receiving drug with less than six months shelf life 6.4

HCW management is open for 24 hours 6.5

Total: VII:- the is proper transportation system for HCW

The edge of HCW trolley and wheel barrow are blunt and will not produce

injury during cleaning 7.1

During HCW transportation the staff has personal protection equipment 7.2

Trolley, wheel barrow and the car is used just for HCW transportation 7.3

HCW transportation will conduct from land fill 7.4

HCW transportation should conducted by authorized team or company which

has legal license 7.5

Total: VIII:- There is proper HCW treatment system in health facility

Cannula, broken ampules, surgical blades and sharps put in safety box 8.1

Used syringe, empty bottle of serum, and vials ‘bottle put in yellow bag and bin

after decontamination with 0.5% chlorine for recycling or go for shredder 8.2

Placenta, surgical pads, part of body, expire blood and lab waste is going along

with other hazardous bio-HCW in red labeled plastic though wheel barrow or

trolley into incinerator or land fill

8.3

There is segregation system before treatment of waste 8.4

In land fill segregated waste are not mixing again 8.5

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Comments 1 0 Standards/ Sub Standards Standard

/ Sub

Standard

#

Total: IX-A:- The ( Regional, Provincial or Tertiary) hospital has standards incinerator or IX -B

The capacity of incinerator is according number of beds or utilization of beds(

0.3-0.5 Kg waste/ bed/day) and has scrubber 9.1

Incinerator has two chambers 9.2

Incinerator has thermometer in outside to show the temperature of inner side 9.3

Incinerator is working both in fuel and electricity 9.4

Incinerator has long chimney pipe ( around 40 feet) 9.5

Total: IX- B:- The health facility has HCW burial system ( Remote clinics or low utilized

There is three well in health facility 9.1

First well for placenta, part of body, contaminated gauze pad or compress( Bio

HCW) 9.2

Second well for sharps and safety box 9.3

Third well for food and general waste 9.4

The wells and land fill located in premises of health facility which is less risky

for environment and water source 9.5

Total: X-A:- The ( Regional, Provincial or Tertiary) hospitals’ incinerator working according to guideline or

Incinerator surrounded with wall, wire and is inaccessible for children and

animal. Top of incinerator covered to protect from sun, rain snow

10.1

Incinerator is installed in premises of hospital away from common road and food

preparation area ( This area should select by team from representative of

hospital, environmental health, municipal sanitation department and NEPA)

10.2

The is storage place close to incinerator for red plastic bin material 10.3

The temperature of first chamber is over 800 celsius and second chamber is over

1000⁰ 10.4

The ash of incinerator is properly placed well or put in safe plastic bag separate

from municipal general waste 10.5

Total: X-B:-The HCW is treating in better way in remote, OPD clinics

People dealing with HCW has personal protection equipment 10.1

There is no access in wells except responsible people 10.2

The wells designed with written and pictorial alert sign 10.3

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Comments 1 0 Standards/ Sub Standards Standard

/ Sub

Standard

#

There is no sharps and waste around HCW 10.4

In case if the well fills, cover the surface with soil and dig a new well 10.5

Total: XI-A: The ( Regional, Provincial or Tertiary)hospital has complementary part of incinerator or

The health facility has microwave and autoclave 11.1

Recycling material ( Syringe, serum bottle and vial) first sterilize in autoclave 11.2

The recycling material goes to shredder after autoclave 11.3

The shredded material go either back to company or burial area 11.4

In case the shredded material goes to burial, it should put into yellow plastic 11.5

Total: XI-B: The health facility treatment the HCW by using the other health facility equipment (Common

Treatment Facility)

The hazardous HCW (Bio Medical) put in red plastic and send to closed health

facility’s incinerator by per plastic or per bed / month charge

11.1

The recyclable material ( syringe, empty bottle of serum ) after decontamination

in 0.5% chlorine put in yellow plastic and send to autoclave and shredder by

payment charge

11.2

The general waste put in black plastic and transport with help of municipal

sanitation department to general waste land fill area

11.3

The vehicle for transportation of HCW is washable, wash the car after each

transportation and cover the surface of HCW during transportation,

11.4

The vehicle for HCW transportation has special permission letter or license and

clearly texted HCW transportation vehicle…..

11.5

Total: XII: There is awareness program regarding HCW in health facility

HCW disposal is one topic of health education program 12.1

IEC material is available regarding HCW awareness and precaution for health

provider and community

12.2

IEC material responding the need of community( Age, language and gender) 12.3

Culture sensitivity respected in IEC material and key health massages 12.4

IEC material posted in area which community has more access 12.5

Please observe the XIII standards if there is accident or hospital spillage or increase infectious complication

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Total: XIII: in case of accidental injury or spillage the hospital takes precaution

Evacuate and clean the area 13.1

Decreases the exposure of staff and increases immunization program 13.2

Place back the taken equipment 13.3

Provide orientation for staff regarding identification and treatment of hospital

contamination

13.4

The responsible person should investigate the cause of accidental injury and

spillage

13.5

Summary table of HCW disposal checklist

13 Number of standards

75 Total of sub standards

Number of sub standards achieved one

Percentage of achievement ( Total of substandard score multiply to 100 divided to 75)

In order to prioritize in planning list the standards from low to high score

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ANNEXURE III: LIST OF CONTACTS

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ANNEXURE IV: LIST OF CONTACT

S.

N

Organization Address Contact Person Designation Phone 1 Phone 2 Email1 email 2 website

1 Kabul

Municipality

Mr. Nessar Ahmad

HabibiGhori

General Director

for Sanitation of

Kabul City

93 0 799

025299

[email protected]

2 Islamic

Republic of

Afghanistan,

National

Environmental

Protection

Agency

Zabihullah Habib

Afrooz

Director of Policy

& Legislation

[email protected] [email protected]

.af

3 Islamic

Republic of

Afghanistan,

Ministry of

Public Health

Mr. Mashal,

Mohammad Taufiq

MD

General Director of

Preventive

Medicine

93 0 708 284

144

202 301 359 [email protected] [email protected]

c.jp

4 Islamic

Republic of

Afghanistan,

Ministry of

Public Health

Mr.Amanullah

Hussaini

Environmental

Health Director

93 0 700 294

312

93 752

003542

[email protected]

om

5 The World Bank Mr. Mohammad

Arif Rasuli

Senior

Environmental

Specialist (South

East Asia)

93 700 171

338

87 376 346

7626

[email protected] www.worldba

nk.org/af

6 The World

Bank,

House 19,

Street 15,

Wazir Akbar

Khan, Kabul

Afghanistan

Dr. G. Sayed Senior Health

Specialist

Afghanistan

Country Office,

South Asia region

93 701 133342

(office)

93 700

042585

[email protected] www.worldba

nk.org/af

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7 The World

Bank,

House 19,

Street 15,

Wazir Akbar

Khan, Kabul

Afghanistan

Mr. Mohammad

TawabHashemi

Extended Term

Consultants (South

Asia Region)

930 799 791

128

[email protected]

rg

www.worldba

nk.org/af

8 EPOS Parwiz Sardar

Mohammad

Technical Advisor

to G.D of

Preventive

Medicine (MoPH)

93 079

9311532

[email protected]

om

9 Islamic

Republic of

Afghanistan,

Ministry of

Public Health,

GCMU

Dr. Mohammad

Hassan

Grant Consultant 93 773 342

830

93 0 700

259 636

[email protected]

.af

edrishassan05@yahoo.

com

10 Islamic

Republic of

Afghanistan,

Ministry of

Public Health,

GCMU

Dr. Mohammad

Saeed MD, EMBA

PGC Grant

Consultant

93 0

700083428

[email protected] dr.muhammadsaeed@

gmail.com

12 Islamic

Republic of

Afghanistan,

Ministry of

Public Health

Pbox : 421 ,

Kabul AFG,

Macrorayan,

Kabul -

Afghanistan

Dr. Abdul Malik

"Malik"

Head of

Department

Radiation

Protection and

Nuclear Medicine

93 0

700205675

[email protected]

m

Abdul.Malik.Dr@gma

il.com

13 Islamic

Republic of

Afghanistan,

Ministry of

Public Health,

GCMU

Shala

Salim/MD/DPH

Communication

Officer

93 0 79

0075068

[email protected].

af

[email protected]

14 Islamic

Republic of

Afghnistan,

Ministry of

Public Health

Eng. Gh.

Mohammad Salem

Administrative

Manager

93 0 799 772

766

[email protected]

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15 Islamic

Republic of

Afghanistan,

Ministry of

Public Health,

GCMU

Dr. Zahidullah

Rasooli MD

Project Manager to

Support the Public

Health Sector

93 0 787 298

233

[email protected]

.af

zahidullah.rasooli@g

mail.com

skype.zahidull

ahrasooli

16 Directorate of

Environmental

Health

Indira

Gandhi

Hospital,

Kabuli

Dr. Naseer ICRC

Head Quarters

(ARCS)

Bio Medical Waste

Project Manager

799108997 [email protected]

17 Construction

Department,

Ministry of

Public Health

Eng. Kamal 78300580

18 Indira Gandhi

Hospital, Kabul

Dr. Yusuf Zai Director

19 Grant Contracts

& Management

Unit, MoPH,

Afghanistan

Ghulam. Sarwar

Hemati,

Managing Director,

EMBA

93 0 799 318

328

93 0 705

470 685

[email protected]

.af

[email protected]

om

20 EPOS MoPH, G.

Massoud

Square,

Wazir Akbar

Khan Mena,

Kabul,

Afghanistan

Mr. Jordi Benages, Team Leader 93 0 78451338 [email protected]

21 Parwan Public

Health

Directorate

Alhaj Dr. Khaja M.

QasimSaidi

700271479 [email protected]

m

22 Khatiz Public

Health

Association

(KPHA)

Kabul,

Afghanistan

Dr. Said Habib

Arwal

President 9.30701E+11 9379911381

6

[email protected] skype: dr.arwal1

23 GCMU, Kabul,

Afghanistan

SahebullahAlam,

MD

Grant Consultant 9.30706E+11 9.30706E+1

1

[email protected]

f

smohammadalam@ya

hoo.com

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24 EPOS MoPH, G.

Massoud

Square,

Wazir Akbar

Khan Mena,

Kabul,

Afghanistan

Dr. Hidayatullah Technical Advisor

to G.D of Curative

Medicine (MoPH)

93 0 799 127

717

[email protected]

m

25 Directorate of

Environmental

Health

Department

Balkh OPH

Dr. Ab. Khalil

Merhabi

0777511313-

0700511313

[email protected]

om

26 GCMU, Kabul,

Afghanistan

Masoud Ahmad (

Yawar), MD

Grant Consultant 9.30701E+11 drmasoudahmad@yahoo.

com

massoud.gcmu@moph

.gov.af

27 Ministry of

Public Health,

Islamic

Republic of

Afghanistan

Dr. Fazal

Muhammad "

Ibrahimi"

Advisor to Minister

, General Director

of Khair Khana102

Beds Hospital

202401352 706088572

28 Food and

Agriculture

Organization of

the United

Nations

Ministry of

Agriculture,

Irrigation and

Livestock,

General

Department

of Policy and

Planning,

Jamal Mina,

Karte Saki,

Kabul,

Afghanistan

Hafizullah Saadat National

Economist/Statistici

an

[email protected]

rg

Hafiz_Saadat@yahoo.

com

www.fao.org

29 EPOS, MOPH Dr. Hidayutallah TA to GD of

Curative Medicine

+93079912771

7

[email protected]

m

30 RBH Hospital Dr. NajiaAlami, Obst/Gyano 0779361698

31 Malalai Hospital Dr. Nasrin

Oynakihil

Trainer Spl. Ob-

Gyn.

0799326087 [email protected]

om

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120

ANNEXURE IV: GUIDELINES FOR SETTING UP WASTE MANAGEMENT

COMMITTEE

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121

Annexure V

Setting up of Waste Management Committee at the Facility Level

Under the Infection Control Policy, for the purpose of the implementation of HCW management Plan at

Facility Level, each and every health care facilities irrespective of their size setting up of the Healthcare

Waste Management Committee needs to be made mandatory and a written commitment (for instance

through Affidavit) needs to be furnished by the top Management/Authority of the Health Care facilities to

the Environmental Health Directorate (EHD).

The management needs to reveal names of the members of the committee and their respective roles. It

would be the responsibility of the committee to monitor and supervise the best practices of Health care

Waste Management at HCFs Level.

The Healthcare Waste Management Committee should include:

1 Heads of the Hospital

2 Waste Management Officer

3 Heads of the Hospital Departments

4 Nursing Superintendent

5 Doctor/Nurse from Infection Control Committee

6 Sanitary Supervisor

7 Store-in Charge and

Continuing

Education

Implementation of

the system

Regular Monitoring

Epidemiology Nurse

(Infection Control Nurse)

Medical Director &

Administration Head

Members from other

department

Waste Management

Committee

Policies & Regulations

Hospital’s Nodal Officer

Nursing Superintendent

Sanitary supervisor store in Charge

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8 Other Housekeeping Staff

The HCWM Committee will also inform Environmental Health Directorate (EHD) about the selection of

treatment technology. For selection of Treatment Technology the assessment and projection of wastes to be

produced at HCFs level needs to be done.

An effective waste management plan includes the following:

Strategy to implement 3R Application (Reduction at Source, Re-Use &Recycling)

Segregation

Composting

Basic Steps in development of a Waste Minimization Program include:

a) Planning & Organization : Getting top management to be committed to waste minimization and

setting up of goals and task force by involving crucial personnel from key departments

b) Assessment: Assessment of wastes flow, waste generation rates by using an audit tool which helps

in prioritizing the waste stream based on quantity, toxicity, environmental impact, potential

liability and cost and other associated factors and selection of technology.

c) Feasibility Analysis: Evaluation of technical and economic viability technology etc.

d) Implementation: Getting approval of top management about the technology or new procedures

to minimize the waste, launch of educational and communication programs to reach out the entire

staff and patients or visitors who are directly involved with the waste production.

e) Period Inspection: Regular monitoring and evaluation helps in identification of new issues, staff

efficiency and education level etc., requirement of further reinforcement etc.

The Major Functions of HCWMC

o Prepare HCWM Plan, as per the guidelines and Policy laid down by the Implementing Agency

or Authority (i.e. NEPA), of its waste with the goal of protecting health and the environment.

o Implement HCWM Plan, review and update the policy, guidelines on an annual basis.

o Ensure adequate financial and human resources for implementation of the Health care waste

management Plan.

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ANNEXURE V: GUIDELINES FOR CONSTRUCTION SHARP AND BURIAL PITS

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Annexure VI

Guidelines for construction Sharp and burial Pits

Design Aspects of Sharps Disposal Pit

Since sharps are usually the main cause of concern, and make up only a small quantity of the total

health care waste, they may be appropriately disposed of on-site. The remaining waste may be sent

to the municipal (or common) disposal site. A system that may be used in small health care centers

is described below.

A circular or rectangular pit is dug and lined with brick, masonry or concrete rings. The pit is

covered with a heavy concrete slab that is with an internal diameter of about 200mm. Needles and

scalpel blades (without the syringe body or drip tubing) are dropped into the pit through the steel

pipe. When the pit is full it can be sealed permanently after another has been prepared. Advantages

of such pits are that these discourage recycling of sharps by scavengers due to their inaccessibility.

The height of the pipe discourages children from dropping soil or stones into the pit filling it up

prematurely.

The Specification for a Waste Burial Pit

The specification for a waste burial pit is provided below.

1 A pit or trench should be dug about 2 meters deep. It should be half-filled with waste, and

then covered with lime up to 50 cm of the surface, before filling the rest of the pit with soil.

2 Animals should not have any access to the waste burial sites. Covers of galvanized

iron/wire meshes may be used to protect the area from trespassing.

3 On each occasion, when wastes are added to the pit, a layer of 10 cm of soil shall be added

to cover the wastes.

4 Waste disposal into the pits should be performed under close and dedicated supervision.

5 The deep burial site should be relatively impermeable and no shallow well should be close

to the site.

6 The pits should be distant from habitation, and sited so as to ensure that no contamination

occurs of any surface water or ground water. The area should not be prone to flooding or

erosion.

7 The location of the deep burial site should be authorized by the prescribed authority

8 The institution should maintain a record of the kind of waste sent for deep burial.

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9 A permanent Record of the size and location of all burial pits needs to be strictly

maintained and displayed at strategic place with due precautions to prevent construction

workers, builders and other from digging in those areas in the future

Figure5.3: Layout Specifications for Burial Pit

(Source “Implementation Experience in India & Tool-Kit for Managers, The

World Bank)

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ANNEXURE VI: COMPARATIVE EVALUATION OF DIFFERENT TECHNOLOGY

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Annexure VII

The Incinerators are being increasingly moved away from the Hospitals & HCFs, the world over

due to a host of factors including high capex&opex, space requirements, lack of technology back-

up support & technical personnel etc. apart from the environment issues. The Burial Pits for the

HCFs in remote locations as well as those which are not linked to CWTFs remain viable disposal

option.

In absence of CWTF pit technology based disposal system can be adopted. The specification for

a waste burial pit have been provided in HCWM Plan at Chapter 5 in detail.

Evaluation of Technologies

It is pertinent to evaluate the advantage and disadvantage of available technology (ies) for effective

HCWM purpose. A comparative evaluation of the technological options for HCWM has been detailed

below.

Advantage & Disadvantages of different Treatment methods

Treatment method Advantages Disadvantages

Rotary kiln

Incineration

Adequate for all infectious waste,

Most chemical waste and

pharmaceutical waste.

Significant reduction of weight and

volume of waste.

High investment and operating costs.

Concern about air emissions.

Controlled air

Incineration

Very high disinfection efficiency.

Adequate for all infectious waste and

Most pharmaceutical and chemical

waste.

Incomplete destruction of cytotoxic.

Relatively high investment and

operating costs.

Concern about air emissions.

Multiple hearth

Incineration

Good disinfection efficiency.

Significant reduction of weight and

volume of waste.

The residues may be disposed of in

landfills.

No need for highly trained operators.

Relatively low investment and

operating costs.

Significant emissions of atmospheric

pollutants.

Need for periodic removal of slag and

soot.

Inefficiency in destroying thermally

resistant chemicals, and drugs such as

cytotoxic.

Chemical

Disinfection

Highly efficient disinfection under

good operating conditions.

Requires highly qualified technicians for

operation of the process.

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Some chemical disinfectants are

relatively inexpensive.

Reduction in waste volume.

Uses hazardous substances that require

Comprehensive safety measures and

safe disposal.

Inadequate for pharmaceutical, chemical

and some types of infectious waste.

Wet thermal

Treatment

Environmentally sound.

Drastic reduction in waste volume.

Relatively low investment and

operating costs

Shredders are subject to frequent

breakdowns and poor functioning.

Operation requires qualified technicians.

Inadequate for anatomical,

pharmaceutical, and chemical waste and

waste that is not readily steam-

permeable.

Microwave

Irradiation

Good disinfection efficiency under

appropriate operating conditions.

Drastic reduction in waste volume.

Environmentally sound.

Relatively high investment and

operating costs.

Potential operation and maintenance

problems.

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ANNEXURE VII : GUIDELINES FOR SETTING UP OF CWTFs

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Annexure VIII

Setting up of Common healthcare Waste Treatment Facility

A Common healthcare Waste Treatment Facility (CWTF) shall have following treatment facilities.

i) Incineration: It is a controlled process where waste is completely oxidized and harmful

microorganisms present in it are destroyed/denatured under high temperature.

ii) Autoclaving/Microwaving/Hydroclaving: Autoclaving is a low-heat thermal process where steam

is brought into direct contact with waste in a controlled manner and for sufficient duration to

disinfect the wastes. For ease and safety in operation, the system should be horizontal type and

exclusively designed for the treatment of health care waste. For optimum results, prevaccuum based

system be preferred against the gravity type system. It shall have tamper-proof control panel with

efficient display and recording devices for critical parameters such as time, temperature, pressure,

date and batch number etc.

In microwaving, microbial inactivation occurs as a result of the thermal effect of electromagnetic

radiation spectrum lying between the frequencies 300 and 300,000 MHz. Microwave heating is an

inter-molecular heating process. The heating occurs inside the waste material in the presence of

steam. Hydroclaving is similar to that of autoclaving except that the waste is subjected to indirect

heating by applying steam in the outer jacket. The waste is continuously tumbled in the chamber

during the process. Though chemical disinfection is also an option for the treatment of certain

categories of bio-medical waste but looking at the volume of waste to be disinfected at the CBWTF

and the pollution load associated with the use of disinfectants, the use of chemical disinfection for

the treatment of bio-medical waste at CBWTF is not recommended.

iii) Shredder: Shredding is a process by which waste are de-shaped or cut into smaller pieces so as to

make the wastes unrecognizable. It helps in prevention of reuse of bio -medical waste and also acts

as identifier that the waste has been disinfected and is safe to dispose of.

A shredder to be used for shredding bio-medical waste shall confirm to the following minimum

requirements.

1 The shredder for bio-medical waste shall be of robust design with minimum maintenance

requirement

2 The shredder should be properly designed and covered to avoid spillage and dust

generation. It should be designed such that it has minimum manual handling.

3 The hopper and cutting chamber of the shredder should be so designed to accommodate the

waste bag full of bio-medical waste.

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4 The shredder blade should be highly resistant and should be able to shred waste sharps,

syringes, scalpels, glass vials, blades, plastics, catheters, broken ampoules, intravenous sets/

bottles, blood bags, gloves, bandages etc. It should be able to handle/ shred wet waste,

especially after microwave/ autoclave/hydroclave.

5 The shredder blade shall be of non-corrosive and hardened steel.

6 The shredder should be so designed and mounted so as not to generate high noise &

vibration

7 If hopper lid or door of collect ion box is opened, the shredder should stop automatically for

safety of operator.

8 In case of shock-loading (non-shred-able material in the hopper), there should be a

mechanism to automatically stop the shredder to avoid any emergency/accident.

9 In case of overload or jamming, the shredder should have mechanism of reverse motion of

shaft to avoid any emergency/accident.

10 The motor shall be connected to the shredder shaft through a gear mechanism, to ensure low

rpm and safety.

11 The unit shall be suitably designed for operator safety, mechanical as well as electrical.

12 The shredder should have low rotational speed (maximum 50 rpm). This will ensure better

gripping and cutting of the bio-medical waste.

13 The discharge height (from discharge point to ground level) shall be sufficient (minimum 3

feet) to accommodate the containers for collection of shredded material. This would avoid

spillage of shredded material.

14 The minimum capacity of the motor attached with the shredder shall be 3 kW for 50 kg/hr, 5

kW for 100 kg/hr& 7.5 kW for 200 kg/hr and shall be three phase induction motor. This will

ensure efficient cutting of the health care wastes. Other specifications have been provided at

Annexure 5.1.

iv) Sharp pit/ Encapsulation: A sharp pit or a facility for sharp encapsulate on shall be provided

for treated sharps. An option may also be worked out for recovery of metal from sharps in a

factory.

v) Vehicle/Container Washing Facility: Every time a vehicle is unloaded, the vehicle and empty

waste containers shall be washed properly and disinfected. It can be carried out in an open area

but on an impermeable surface and liquid effluent so generated shall be collected and treated in

an effluent treatment plant. The impermeable area shall be of appropriate size so as to avoid

spillage of liquid during washing.

vi) Effluent Treatment Plant: A suitable Effluent Treatment Plant shall be installed to ensure that

liquid effluent generated during the process of washing containers, vehicles, floors etc. is

disposed after treatment. The treated effluent shall comply with the stipulated regulator y

requirements.

Infrastructure Set up

The following infrastructure needs to be set up for CWTF

i) Treatment Equipment Room

ii) Main Waste Storage Room

iii) Treated Waste Storage Room

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iv) Administrative Room

v) Generator Set

vi) Site Security

vii) Parking

viii) Sign Board

ix) Green Belt

x) Washing Room

Besides above following important provision should be made in CWTF

o A Telephone

o First Aid Box

o Proper Lighting

o Proper Fire Fighting Facilities

o Measures to control pests and insects at the site

o Safety gears for the waste handlers

o Record Keeping

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LIST OF REFERENCES

1. Afghanistan’s Environment(2008), Executive Summary (NEPA)

2. Ministry of Public Health (MoPH) Strategic Plan(2011-15)

3. Preliminary Healthcare Waste Management Plan for SEHAT Project, MOPH (Nov 2012)

4. Mainstreaming Environmental Management in the Healthcare Sector- implementation

experience in India and a toolkit for managers vol. 1 & 2 (The World Bank, Feb 2012)

5. Healthcare Waste Mgmt Guidelines (Dari Version)

6. Afghanistan Health Profile

7. Afghanistan Provincial Health Profile-Situational Analysis of Provincial Health Services

(MoPH HMIS DEPTT.)

8. Article 'UNDP-“Health without Harm”.

9. Biomedical Waste Management RULES India (1998) and Draft BMW Rules India (2011)

10. Draft New BIO Medical Waste Management Rules

India (2011)

11. Infection Management and Environment Plan, Policy Framework, MoHFW, Govt. of India

(March 2007)

12. Rapid HealthCare Waste Mgmt tool (RAT) .WHO,UNEP/SBC,2004

13. CPCB Guidelines for establishing and operating Common Bio Medical Waste treatment

facility.

14. Manual on Safe Management of Wastes from HealthCare Facilities (WHO)

15. Guidelines for Environmental Infection Control in HealthCare Facilities (CDC, Atlanta).

16. Health Services Support Project (HSSP), July 2006-Oct 2012, USAID, Afghanistan.

17. Country Update, The World Bank Group in Afghanistan, Issue 042, March 2013.

18. Ambient Air Standards of Afghanistan, NEPA,2011.

19. Policy on MSW Management (Dari Version), Kabul Municipality.

20. World Bank Safeguard Policies (MAY 2007) and the updates

21. Technical Committee On Geotechnics of Landfill Engineering, German Geotechnical

Society(DGCT)-Toolkit for Landfill Technology, June2009

22. Extension of Consultancy services for Sanitation Improvement in Kabul City-Report of

Environment expert-Construction of New Landfill Site in

District#17.

23. Environmental Health Policy of Afghanistan (Draft)

24. Infection Prevention (IP) Plan Document, MoPH, Afghanistan

25. SEHAT Project Documents, Afghanistan

26. National Health and Nutrition Sector Strategy, Afghanistan

27. Health & Nutrition Policy

28. Afghan Private Hospital Association (APHA) Guidelines.